F19T4EXI
2019-2020 Independent Income Exclusion Worksheet
Student Name: SMC ID#
ENTER 0 FOR ANY ITEMS THAT DO NOT APPLY. DO NOT LEAVE ANY FIELDS BLANK!
Student Calendar Year 2017 Spouse
$
Child support paid because of divorce or separation or as a result of a
legal requirement. Do not 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 and scholarship portions of
fellowships and assistantships.
$
$
Combat pay or special combat pay that was reported to the IRS in your
adjusted gross income. DO NOT INCLUDE UNTAXED COMBAT PAY.
$
$
Earnings from work under a cooperative education program
offered by a college.
$
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
Spouse Signature Spouse Printed Name Date
Office of Student Financial Services
One Winooski Park, Box 4
Colchester, VT 05439
Tel. 802-654-3243
Fax: 802-654-2591
