F19T4EXD
2019-2020 Dependent Income Exclusion Worksheet
Student Name: SMC ID#
ENTER 0 FOR ANY ITEMS THAT DO NOT APPLY. DO NOT LEAVE ANY FIELDS BLANK!
REPORT CALENDAR YEAR 2017
INCOME INFORMATION
Student Calendar Year 2017 Parent
$
Child support paid because of divorce or separation or as a result of a
legal requirement. Don’t include support for children included in your
household on the 2019-2020 FAFSA.
$
$
Taxable earnings from need-based employment programs such as
Federal Work Study and need-based employment portions of
fellowships and assistantships.
$
$
Taxable grant and scholarship aid reported to the IRS as income. Include
AmeriCorps benefits (awards, living allowances and interest accrual
payments), as well as grant & scholarship portions of
fellowships and assistantships.
$
$
Combat pay or special combat pay, that was taxable and included in your
(or your parents’) adjusted gross income. DO NOT INCLUDE UNTAXED
COMBAT PAY.
$
$
Earnings from work under a cooperative education program
offered by a college.
$
2017 Child Support Paid
Did the student or parent pay child support because of divorce or separation during calendar year 2017? YES NO
(Do not include support paid for children included in household size.)
If yes, please provide the following:
Name of the person who
paid
the child support
Name of the person to whom
the child support was paid
Name and age of the child for whom the
child support was paid
support paid in
CERTIFICATION: I certify that all the information reported on this form is true, complete and correct. I understand that
any false statements could be cause for denial, reduction, withdrawal or repayment of financial aid.
Please print and sign before submitting. We CANNOT
accept digital signatures.
Student Signature Date
Parent Signature Parent Printed Name Date
Office of Student Financial Services
One Winooski Park, Box 4
Colchester, VT 05439
Tel. 802-654-3243
Fax: 802-654-2591
