Fillable 2019-2020 Verification Of Other Untaxed 2016 Income Fillable

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2019-2020 Verification Of Other Untaxed 2016 Income Fillable

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2019-2020 Verification of Other Untaxed Income Page 1 of 3 19UNTAX
If any item does not apply, enter “N/A” for not applicable where a response is requested, or enter “0” in an area where an
amount is requested.
DEPENDENT
Parent REQUIRED to sign FAFSA or CADAA
INDEPENDENT
Parent NOT REQUIRED to sign FAFSA or CADAA
• Answer each question below as it applies to the student and the
student’s parent(s) whose information is on the Free Application for
Federal Student Aid (FAFSA) or CA Dream Act Application (CADAA).
• Parent signature required
•
Answer each question below as it applies to the student (and the
student’s spouse, if married) whose information is on the Free
Application for Federal Student Aid (FAFSA) or CA Dream Act
Application (CADAA).
To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in 2017,
multiply that amount by the number of months in 2017 you paid or received. If you did not pay or receive the same amount
each month in 2017, add together the amounts you paid or received each month.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
A. 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
B. Child Support Received
List the actual annual 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
C. 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
2019-2020 VERIFICATION OF OTHER UNTAXED 2017 INCOME
STUDENT INFORMATION
Please PRINT clearly with black/blue ink
First Name
M.I
Student ID Number
2019-2020 Verification of Other Untaxed Income Page 2 of 3 19UNTAX
D. 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 allowances.
Do not include Federal veteran’s 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-Educational Benefit
Amount of Benefit
Received in 2017
E. 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 student aid, Earned Income Credit,
Additional Child Tax Credit, Temporary Assistance to Need Families (TANF), untaxed Social Security benefits, Supplemental
Security Income (SSI), Workforce Investment Act (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.
Name of Recipient
Type of Other
Untaxed Income
Amount of Other
Untaxed Income
Received in 2017
F. 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 2016. Include support from a parent whose
information was not reported on the student’s 2019-2020 FAFSA or CADAA, but 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 or CADAA. 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 in 2017 Source
2019-2020 VERIFICATION OF OTHER UNTAXED 2017 INCOME
STUDENT INFORMATION
Please PRINT clearly with black/blue ink
First Name
M.I
Student ID Number
2019-2020 Verification of Other Untaxed Income Page 3 of 3 19UNTAX
G
. Additional Information
So that we can fully understand the student’s family’s financial situation, please provide below information about any other
resources, benefits, and other amounts received by the student and any members of the student’s household. This may
include items that were not required to be reported on the FAFSA, CADAA or other forms submitted to the financial aid
office, and include such things as federal veteran’s education benefits, military housing, SNAP, TANF, etc.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
Name of Recipient Type of Financial Support
Amount of Financial
Support Received in 2017
H
. Comments
If you and/or your parent(s) (if dependent) did not receive any other untaxed income in 2017, please give a detailed
explanation of how you and/or your parent (if dependent) were able to meet your household’s financial obligations,
including monetary amounts. (You may attach a separate sheet or write on the reverse side if additional space is needed.)
C
ERTIFICATION
I
/WE HEREBY CERTIFY THAT ALL INFORMATION REPORTED ON THIS FORM AND ANY ATTACHMENTS HERETO ARE TRUE, COMPLETE
AND ACCURATE. FALSE INFORMATION OR MISREPRESENTATION WILL BE CAUSE FOR DENIAL, REDUCTION, WITHDRAWAL, AND/OR
REPAYMENT OF FINANCIAL AID.
__________________________________________________________________ ___________________
Student’s Signature Date
__________________________________________ ___________________________________________ ___________________
Parent’s Name (Please print) Parent’s Signature (Required if student is DEPENDENT) Date
20
19-2020 VERIFICATION OF OTHER UNTAXED 2017 INCOME
STUDENT INFORMATION
Please PRINT clearly with black/blue ink
First Name
M.I
Student ID Number
SJC Financial Aid Office * 1499 N State Street * San Jacinto, CA 92583 * Telephone: (951) 487-3245
MVC Financial Aid Office * 28237 La Piedra Road * Menifee, CA 92584 * Telephone: (951) 639-5245
Email: finaid@msjc.edu * Website: www.msjc.edu
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Completed 5 November 2019

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