Fillable 2019 2020 Parent Untaxed Income Formfor Tax Year2017 (Virginia Western Community College)

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2019 2020 Parent Untaxed Income Formfor Tax Year2017 (Virginia Western Community College)

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The 2019 2020 Parent Untaxed Income Formfor Tax Year2017 (Virginia Western Community College) form is 2 pages long and contains:

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2019-2020 Parent Untaxed Income Form
The U.S. Department of Education selected your student’s 2019-2020 FAFSA for review after comparing your 2017 Adjusted
Gross Income and other untaxed income. You and your spouse, if you are married, must complete form. You and your
student must print, sign, and submit the form. Instructions for submission are at the end of the form.
You and your spouse, if you are married, must complete this form. One parent and the student must sign and submit this
form to the Financial Aid Office to continue the verification review process.
A. Student Information
B. Untaxed Income Information
Report total annual amounts for 2017. If an item does not apply, enter “0” or “N/A.” Boxes left blank will result in additional information 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.
First Name
MI
Last Name
VWCC Student ID - Required
Untaxed Income Item to Verify:
Parent Name(s) for whom the information below is being reported (first and last
name(s)
Parent One:
Total 2017 Amount:
Parent Two:
(if Parent is married)
Total 2017 Amount:
Parent One Name:
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 2016 for any children in your household. If additional space is needed attach a separate
piece of paper with required information. Do not include foster care payments, adoption payments, or court-order amounts not actually paid.
LIST NAME OF CHILD(REN):
$
$
$
$
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 one 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 Signature Date
______________________________________________________________________ _______________
Parent Signature Date
HOW TO SUBMIT THIS FORM
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 Parnt Untaxed Income 2017’ from the ‘To Do List’ list to attach and upload the form. You can also 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. Fax forms to 540-857-6208
♦
Phone: (855)874-6690
Untaxed Income Item to Verify - CONTINUED:
Parent One:
Total 2017 Amount:
Parent Two:
(if Parent is married)
Total 2017 Amount:
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:
$
$
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:
$
$
SOURCE:
$
$
First Name
MI
Last Name
VWCC Student ID - Required
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2019 2020 Parent Untaxed Income Formfor Tax Year2017 (Virginia Western Community College)

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Completed 27 July 2020

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