F19UNTXI
2019-2020 Independent Student Untaxed Income 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
$
Payments to tax-deferred pension and retirement savings plans (paid directly or withheld from
earnings), including, but not limited to amounts reported on the W-2 Form in Box 12a-12d, codes D,
$
$
Child support received for all children. Do not include foster care or adoption payments.
$
$
Housing, food, and other living allowances paid to members of the military, clergy, and others
(including cash payments and cash value of benefits). Do not include the value of on-base military
housing or the value of a basic military allowance for housing.
$
$
Veterans’ non-education benefits, such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC) and/or VA Educational Work-Study allowances. Do not include veterans
educational benefits such as: Montgomery GI Bill, Post-9/11 GI Bill
$
$
Any other untaxed income or benefits, not reported elsewhere on this worksheet, such as worker’s
compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS
Form 1040 Line 25, Railroad Retirement Benefits etc. DON’T INCLUDE extended foster care benefits,
student aid, Earned Income Credit, Additional Child Tax Credit, welfare payments, untaxed Social
Security benefits, Supplemental Security Income, Workforce Innovation and Opportunity Act
educational benefits, on-based military housing or a military housing allowance,
from flexible spending arrangements (e.g. cafeteria plans), foreign income exclusion, or credit for
federal tax on special fuels. Identify the source(s) of untaxed income, if applicable:
Student Spouse
$
$
Cash received, or any money paid on your behalf, not reported elsewhere on this form. For example,
if someone is paying the student’s rent or tuition bills or gives the student cash, report the value of
those contributions.
$
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 (if applicable) 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
