2020-2021 Independent Student Support Form
Student’s Last Name
Student’s First Name
MI
Student’s SSN or ID Number
Student’s Email Address
Student’s Phone Number
Student’s Date of Birth
Please Note: This form asks for amounts from two different years. The other untaxed income and child support
received uses 2017 information. The additional financial support uses 2018 information.
Other Untaxed Income
Answer each question below as it applies to the student and the student’s spouse (if married).
If any Item does not apply enter “N/A” for Not applicable where a response is requested or enter 0 (zero) if an area where an amount
is requested.
2018 IRS W-2 Forms: Copies of all 2018 IRS W-2 Forms issued by the employers to the student and spouse must be provided.
To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in 2018 multiply
that amount by the number of months in 2018 you paid or received it. If you did not pay or receive the same amount each month in
2018 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.
Name of Person Who had Untaxed Income
Type of Untaxed Income Received in 2017
Student Amount
Spouse Amount
in 2017 for 2017 for 2017
Joe Jones
Money received or paid on the students
$500.00
0
behalf
Other Untaxed Income includes: Untaxed income not reported and not excluded elsewhere on this form. Include untaxed income
such as workers’ compensation, disability benefits, black lung benefits, untaxed portions of health savings accounts from IRS Form
1040 line 25, railroad retirement benefits etc.
Do not include: items reported or excluded in the table above. In addition, do not include: extended foster care benefits, student aid,
earned income credit, additional child tax credit, TANF, untaxed social security benefits, SSI, WIOA educational benefits, on -base
military housing or a military housing allowance, combat pay, benefits from flexible spending arrangements, foreign income exclusion or
credit for federal tax on special fuels.
Child Support Received
Complete this section if child support was received in 2015 for any 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 Child
Name of Child for Whom Support Was
Annual Amount of Child Support
Support in 2017 Received in 2017 Received in 2017
Joe Jones
Josh Jones
$5,000
Total Amount of Child Support Received
$
1
Office of Financial Aid~ Louisiana College
1140 College Drive ~ LC Box 582 Pineville, La. 71359
Ph: 318-487-7386 Fax: 318-487-7449 email - financial_aid@lacollege.edu
Additional Financial Support
Please provide information about any other resources, benefits and other amounts received by the student, spouse and any members
of the student’s household. This may include items that were not required to be reported on the FAFSA or other forms submitted to the
financial aid office, and includes such things as federal veterans’ education benefits, military housing, SNAP, TANF, etc.
Please complete all sections of the form, for items that do not apply indicate with a “0” for amounts and “n/a” for other information.
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 Support in 2018
Amount of Financial Support Received in
2018
Jim Jones (example)
SNAP
$4164
AFDC Benefits (Specify Type)
TANF
SNAP
Housing Assistance (Specify Type)
Utility Assistance (Specify Type)
WIC
WIA
Medicaid/SSI (Specify Type)
Combat Pay
Unemployment compensation
Student Aid used for living expenses
Alimony
If you received other assistance that is not listed above please provide an explanation below with the type and amount of the
assistance provided. For example if your family lives with someone who provides you room and board please provide their name,
relationship to you and an estimate for the amount of support provided.
Comments:
CERTIFICATION AND SIGNATURES
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. Please note - If you
purposely give false or misleading Information on this worksheet, you may be fined, be sentenced to jail, or both.
The student must sign and date.
Student’s Signature
Date
Spouse’s Signature (optional)
Date
If you have any questions, please contact your financial aid administrator.
2
Office of Financial Aid~ Louisiana College
1140 College Drive ~ LC Box 582 Pineville, La. 71359
Ph: 318-487-7386 Fax: 318-487-7449 email - financial_aid@lacollege.edu
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