2019 – 2020 VERIFICATION OF UNTAXED INCOME
This information is being requested because the U.S. Department of Education would like to verify the amount of untaxed income
received for 2017. Dependent students should complete both the Parent and the Student columns. Independent students should
complete the Student column and enter zeros in the Parent column. Do not leave any part of this section blank. If not applicable,
enter zero.
STUDENT: STUDENT ID:
(and spouse,
TYPE OF UNTAXED INCOME RECEIVED IN 2017 CALENDAR YEAR
(dependent
$
Payments to tax-deferred pension and retirement savings plan (paid directly or withheld from earnings),
including, but not limited to, amounts reported on the W-2 Form in Boxes 12a through 12d, codes D, E, F,
G, H, and S. Don’t include amounts reported in code DD (employer contributions toward employee health
benefits);
$
$
Tax-deductible payments made to IRA, self-employed SEP, SIMPLE, Keogh, and other qualified accounts
plans. (IRS Form 1040 – lines 28-32, 1040A – line 17);
$
$ Child support received for all children. Don’t include foster care or adoption payments; $
$ Tax exempt interest income from IRS Form 1040 – line 8b or 1040A – line 8b; $
$
Untaxed portions of IRA distributions from IRS Form 1040 – lines (15a minus 15b) or 1040A – lines (11a
minus 11b). Exclude rollovers. If negative, enter a zero;
$
$
Untaxed portions of pensions from IRS Form 1040 – lines (16a minus 16b) or 1040A – lines (12a minus 12b).
Exclude rollovers. If negative, enter a zero;
$
$
Housing, food, and other living allowances paid to members of the military, clergy, and others (including
cash payments and the cash value of benefits). Do not include the value of on-base military housing or the
value of a basic military allowance for housing ;
$
$
Veteran’s non-education benefits such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC), and/or VA Educational Work-Study allowances. Do not include Federal Veterans
education benefits such as: Montgomery GI Bill (Ch. 30), Dependents Educational Assistance Program
(DEAP), VA Vocational Rehabilitation Program, VEAP benefits, or Post-9/11 GI Bill (Ch. 33);
$
$
Other untaxed income not reported, such as workers’ compensation, disability, etc. Also include the
untaxed portions of health savings accounts from IRS Form 1040-line 25. Don’t include extended foster care
benefits, student aid, earned income credit, additional child tax credit, welfare payments, Social Security
benefits, SSI, Workforce Investment Act 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.
$
$ Money received, or paid on your behalf (e.g. bills) not reported elsewhere on this form. $
$ TOTAL $
All of the inform
ation provided on this form and the FAFSA is true and complete to the best of my knowledge. I
understand that if I purposely give false or misleading information on this form or the FAFSA, I may be subject to a
$20,000 fine, imprisonment, or both.
Student Signature Date
Parent Signature Parent Name (Printed) Date
