Fillable 2020-2021 VERIFICATION OF OTHER UNTAXED 2018 INCOME (Mt. San Jacinto Community College District)

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2020-2021 VERIFICATION OF OTHER UNTAXED 2018 INCOME (Mt. San Jacinto Community College District)

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2020-2021 Verification of Other Untaxed Income Page 1 of 3
20UNTAX
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 2018,
multiply that amount by the number of months in 2018 you paid or received. 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.
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 2018
B. C
hild Support Received
List the actual annual amount of any child support received in 2018 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 2018
C. Ho
using, 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 2018
2020-2021 VERIFICATION OF OTHER UNTAXED 2018 INCOME
STUDENT INFORMATION
Please PRINT clearly with black/blue ink
Last Name
M.I
Student ID Number
P R I N T
C L E A R
2020-2021 Verification of Other Untaxed Income Page 2 of 3
20UNTAX
D. Veterans Non-Education Benefits
List the total amount of veteran’s non-education benefits received in 2018. 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 2018
E. O
ther 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 2018
F. M
oney 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 2018. Include support from a parent whose
information was not reported on the student’s 2020-2021 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 2020-2021 FAFSA or CADAA. Amounts paid on the student’s behalf also include any
di
stributions to the student from a 529 plan owned by someone other than the student or the student’s parents, such a
s
grandparents, aunts, and uncles of the student.
Purpose: e.g., Cash, Rent, Books Amount Received in 2018 Source
20
20-2021 VERIFICATION OF OTHER UNTAXED 2018 INCOME
STUDENT INFORMATION
Please PRINT clearly with black/blue ink
Last Name
M.I
Student ID Number
2020-2021 Verification of Other Untaxed Income
Page 3 of 3
20UNTAX
G. Ad
ditional 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 2018
H. Co
mments
a. If you and/or your parent(s) (if dependent) did not receive any other untaxed income in 2018, 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.)
b. If you have a dependent now and are under 24, please give detailed information on how you are currently providing
support for your household’s financial obligations.
CERTIFICATION
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
__________________________________________
Parent’s Name (Please print)
___________________________________________
Parent’s Signature (Required if student is DEPENDENT)
___________________
Date
__________________
Date
2020-20
21 VERIFICATION OF OTHER UNTAXED 2018 INCOME
STUDENT INFORMATION
Please PRINT clearly with black/blue ink
Last Name
M.I
Student ID Number
Mt. San Jacinto College Financial Aid Office
Website: https://msjc.edu/financialaid/
Virtual Lobby: https://msjc.edu/hub/
Telephone: (951) 487-3245
Email: Finaid@msjc.edu
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2020-2021 VERIFICATION OF OTHER UNTAXED 2018 INCOME (Mt. San Jacinto Community College District)

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Completed 5 September 2020

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