Fillable 2019 - 20 Parent Untaxed Income Form (J Sargeant Reynolds Community College)

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2019 - 20 Parent Untaxed Income Form (J Sargeant Reynolds Community College)

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2019–2020 Parent Untaxed Income Form
Your student’s financial aid application was selected by the U.S. Department of Education for review after 2017 Adjusted
Gross Income and other untaxed income was compared. You and your spouse, if you are married, must complete this form.
You and your student must sign and submit the form.
Do not leave any section blank. If an item does not apply enter “0” or “N/A” in the associated space. The form must be
submitted to the Financial Aid Office to continue the review process and determine your eligibility for federal student aid.
A. Student Information
__________________________________________________ ________________
Student’s Name (Last, First, M.I.) Student ID - REQUIRED
B. Untaxed Income Information
Report total annual amounts for 2017. If an item does not apply use “0” or “N/A.” Boxes left blank will result in additional
information being requested. Additional requests to clarify conflicting information may delay the determination of your
student’s financial aid eligibility. If more space is needed, provide a separate page with your student’s name and student ID
number at the top.
Untaxed Income Item to Verify:
Parent Name(s) for whom the information below is being reported (first and
last
name(s)):___________________________________________________________
___________________________________________________________________
Parent’s Total
2017 Amount:
Spouse’s Total
2017 Amount (if
parent is
married):
Payments made to tax-deferred pension and retirement savings plans. List any
payments (direct or withheld from earnings) to tax-deferred pension and
retirement savings plans (e.g., 401(k) or 403(b) plans), including, but not limited
to, amounts reported on W-2 forms in Boxes 12a through 12d with codes D, E, F,
G, H, and S.
$
$
IRA Deductions & payments to self-employed SEP, SIMPLE, Keough, and other
qualified plans. List the total amounts from IRS 1040 – line 28 and line 32 or IRS
1040A – line 17.
$
$
Child Support Received. List actual amount received in 2017 for any children in
your household. Do not include foster care payments, adoption payments, or
court-order amounts not actually paid. SUPPORT FOR THIS CHILD(REN):
__________________________________________________________________
ADULT RECEIVING PAYMENT: _________________________________________
__________________________________________________________________
$
$
Untaxed Portions of IRA distribution. List amount from IRS 1040 – line 15a
minus 15b or IRS 1040A – line 11a minus 11b. Exclude Rollovers. If the value is
negative enter ‘0’.
Tax exempt interest income. List amounts from IRS 1040 – line 8b or IRS 1040A –
line 8b.
$
$
Untaxed Portions of Pension distribution. List amount from IRS 1040 – line 16a
minus 16b or IRS 1040A – line 12a minus 12b. Exclude Rollovers. If the value is
negative enter ‘0’.
$
$
C. Certification and Signatures
The student and the parent for whom information is provided above MUST sign and date this section. Each person signing
below certifies that all the information reported on this form is complete, correct, and any additional information is attached, if
necessary. WARNING: If you purposely give false or misleading information on this worksheet you may be fined, sentenced
to jail, or both.
______________________________________________________________________ _______________
Student’s Signature Date
______________________________________________________________________ _______________
Parent Signature Date
Untaxed Income Item to Verify - CONTINUED:
Parent’s Total
2017 Amount:
Spouse’s Total
2017 Amount (if
parent is
married):
Housing, food, and other living allowances paid to members of the military,
clergy, and others. Include cash payments and cash value of benefits. Do not
include the value of on-base military housing or the value of a basic military
housing allowance (BAH).
$
$
Veteran’s non-education benefits. List the total 2017 amounts including
disability, death pension, Dependency and Indemnity Compensation (DIC), and/or
VA Educational Work-Study allowances.
Do not include federal veterans’
educational benefits like the Montgomery GI Bill, Dependents Education
Assistance Program, VEAP Benefits, or the Post 9/11 GI Bill. TYPE OF BENEFIT:
_________________________________________________________________
_________________________________________________________________
$
$
Other items not reported above. Include items such as worker’s compensation,
disability, Black Lung Benefits, untaxed portions of health savings accounts from
IRS 1040, Line 25, Railroad Retirement Benefits, etc. Do not include student aid,
earn income credit, additional child tax credit, TANF, SNAP, SSI, WIA, Educational
benefits, combat pay, benefits from flexible spending arrangements (e.g.,
cafeteria plans), foreign income exclusion, or credit for federal tax on special
fuels.
SOURCE: _________________________________________________________
RECIPIENT: _______________________________________________________
_________________________________________________________________
$
$
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2019 - 20 Parent Untaxed Income Form (J Sargeant Reynolds Community College)

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Completed 27 July 2020

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