Fillable 2019-2020 Income Level Verification for 2017 (Virginia Western Community College)

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2019-2020 Income Level Verification for 2017 (Virginia Western Community College)

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Page 1 of 3
2019-2020 Income Level Verification for 2017
The U.S. Department of Education selected your student’s 2019-2020 FAFSA for review. You or your parent(s) reported zero
income on the FAFSA for 2017. You are required to complete this form for review of any untaxed income that may have
been used to support your or your parent’s household. Review the instructions below, complete the form accordingly, and
submit to the Financial Aid Office along with other required documentation.
Select applicable statement and complete form accordingly:
I, the student, was required to provide parental
information on the 2019-2020 FAFSA. The
answers on this form reflect information for me
and/or my parents.
I, the student, was not required to provide
parental information on the 2019-2020 FAFSA.
The answers on this form reflect information from
me and/or my spouse, if married.
IMPORTANT INFORMATION:
• If any item does not apply, enter “N/A” for Not Applicable where a response is requested or enter 0 (zero) in an
area where an amount is requested.
• The amounts reported must be the total yearly amount.
A. Federal and other Benefits received in 2017 or 2018: Please select any of the benefits listed below or list any other
benefits that you or someone in your household received.
Federal Benefits Received 2017 or 2018
Name of Recipient
Amount Received
Medicaid
Supplemental Security Income (SSI)
Free or Reduced Price School Lunch
Temporary Assistance for Needy Families
(TANF)
Special Supplemental Nutrition Program for
Women, Infants and Children (WIC)
Other Benefits Received for 2017:
List each benefit
Name of Recipient Amount Received
B. Payments to tax-deferred pension and retirement savings: 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.
Name of Person who made the payment
Total Amount Paid in 2017
First Name
MI
Last Name
Page 2 of 3
Student Name
Student ID
C. Child support received:
List the actual amount of any child support received in 2017 for the children in your household.
Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid.
Name of Adult Who Received the
Support
Name of Child For Whom
Support Was Received
Amount of Child Support
Received in 2017
D. Housing, food, and other living allowances paid to members of the military, clergy, and others: Include cash payments
and/or the cash value of benefits received.
Do not include the value of on-base military housing or the value of a basic military allowance for housing.
Name of Recipient
Type of Benefit Received
Amount of Benefit Received in 2017
E. Veterans non-education benefits:
List the total amount of veterans non-education benefits received in 2017. Include Disability, Death Pension,
Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowance.
Do not include federal veterans educational benefits such as: Montgomery GI Bill, Dependents Education Assistance
Program, VEAP Benefits, Post-9/11 GI Bill
Name of Recipient
Type of Veterans
Non-education Benefit
Amount of Benefit
Received in 2017
F. Other untaxed income:
List the amount of other untaxed income not reported and not excluded elsewhere on this form.
Include untaxed income such as: workers’ compensation, disability, Black Lung Benefits, untaxed
portions of health savings accounts from IRS Form 1040 Line 25, Railroad Retirement Benefits, etc.
Do not include:
any items reported or excluded in A – D above. In addition, do not include extended foster care
benefits, student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families
(TANF), untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Innovation and
Opportunity Act (WIOA) educational benefits, on-base military housing or a military housing allowance, combat pay,
benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal
tax on special fuels.
Name of Recipient Type of Other Untaxed Income
Amount of Other Untaxed
Income Received in 2017
Page 3 of 3
Student Name
Student ID
G. STUDENT ONLY: Money received or paid on the student’s behalf:
List any money received or paid on the student’s behalf (e.g., payment of student’s bills) and not reported elsewhere
on this form. Enter the total amount of cash support the student received in 2017. Include support from a parent
whose information was not reported on the student’s 2019–2020 FAFSA. Do not include support from a parent
whose information was reported. For example, if someone is paying rent, utility bills, etc., for the student or gives
cash, gift cards, etc., include the amount of that person's contributions unless the person is the student’s parent
whose information is reported on the student’s 2019-2020 FAFSA. Amounts paid on the student’s behalf also include
any distributions to the student from a 529 plan owned by someone other than the student or the student’s parents,
such as grandparents, aunts, and uncles of the student.
Purpose: e.g., Cash, Rent, Books
Amount Received by student in 2017
Source
SAMPLE Cell Phone Bill
$600.00
Father
Additional information:
So that we can fully understand the student’s family's financial situation, please provide below information about any
other financial support that was received for 2017 that has not already been listed. If more space is needed, provide a
separate page with the student’s name and ID number at the top.
Additional details: Please provide details of financial support for 2017 not reported in any other section of this form
Certification and Signature: Each person signing this form certifies that all the information reported here is complete and correct.
The student must sign and date below. If the student is a dependent student for the purpose of applying for Federal Student Aid,
then the parent signature and date is also required.
______________________________________________________________________ _______________
Student Signature Required Date
______________________________________________________________________ _______________
Parent Signature If a Dependent Student (If due to the current national situation your Date
parent cannot sign the form, complete section below)
My parent is not able to sign because _____________________________________________________________________________
________________________________________________________________________________________ _____________________
Student Initials Required
WAYS TO SUBMIT THIS FORM
(1) Upload this form directly into the Student Information System (SIS) by logging into MY VWCC. Once logged in, go to the Student
Center and select the ‘VWCC 19/20 Dependent # in Coll’ from the ‘To Do List’ list to attach and upload the form. (2) Upload the form
at www.virginiawestern.com
by clicking ‘Contact Us,’ and then clicking the 24/7 Student Support icon. Once you log in you can
submit documents. (3) Fax forms to 540-857-6208
♦
Phone: (855)874-6690 (Revised 04_2020)
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2019-2020 Income Level Verification for 2017 (Virginia Western Community College)

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Completed 27 July 2020

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