FINANCIAL AID OFFICE
2020-2021 Verification
Other Untaxed Income
185 Freedlander Drive | Clyde, NC 28721 | 828.627.4756 or 1.866.GoToHCC | fax: 828.627.4513 | hccaid@haywood.edu
Your 2020-2021 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. Federal guidelines
dictate that, before awarding federal student aid, we may ask you to confirm the information reported on your FAFSA. To verify that you
provided correct information, we will compare your FAFSA with the information on this institutional verification document and with any
other required documents. If there are differences, your FAFSA may be corrected. The student and the parent whose information was
reported on the FAFSA (if dependent) must complete and sign this form, attach any required documents, and submit the information to the
Financial Aid Office (FAO). If you have questions, please contact the FAO promptly to avoid delays in the processing of your financial aid.
____________________________________________________ ____________________________
Last Name First Name M.I. HCC ID # or SSN (last 4 digits)
____________________________________________________ ____________________________
Street Address (include apt. no.) Date of Birth
____________________________________________________ ____________________________
City State Zip Code Email Address
____________________________________________________ ____________________________
Home Phone Number (include area code) Alternate or Cell Phone Number
DEPENDENT STUDENT- Answer each question as it applies to the student and the student’s parent(s) whose information is on
the FA
FSA.
INDEPENDENT STUDENT
- Answer each question as it applies to the student and the student’s spouse (if married) whose
information is on the FAFSA.
1. Attach copies of all 2018 IRS W-2 forms issued by the employers to the dependent student and the student’s
parents or to the independent student and spouse, if student is married. List the people for whom W-2 forms
have been attached, including student: ____________________________________________________________
NOTE WHEN COMPLETING ITEMS #2 - #8:
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 ANY ITEM DOES NOT APPLY, enter “N/A” for Not Applicable where a response is requested, or enter “0” where an amount
is requested.
If more space is needed, attach a separate page with student’s name and HCC ID number at the top.
2. 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
Annual Amount Paid in 2018
Total Payments to Tax-Deferred Pension and Retirement Savings
$
FINANCIAL AID OFFICE
2020-2021 Verification
Other Untaxed Income
185 Freedlander Drive | Clyde, NC 28721 | 828.627.4756 or 1.866.GoToHCC | fax: 828.627.4513 | hccaid@haywood.edu
3. Child support received
List the actual 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
Total Amount of Child Support Received
$
4. 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 a basic military housing allowance.
Name of Recipient Type of Benefit Received
Total Amount of Benefits Received
5. Veterans’ non-education benefits
List the total amount of veterans’ 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 veterans’ educational benefits such as: Post-9/11 GI Bill, Montgomery GI Bill, Dependents Education
Assistance Program, and VEAP Benefits.
Name of Recipient
Type of Veterans’
Non-education Benefit
Total Amount of Benefits Received
6. 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 #2-5 above. In addition, do not include student aid, Earned Income Credit,
Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed Social Security benefits, Supplemental
Security Income (SSI), Workforce Investment Act (WIOA) 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
Total Amount of Other Untaxed Income
$
_______________________________________________ ______________________
Print Student’s Name HCC ID # or SSN (last 4 digits)
FINANCIAL AID OFFICE
2020-2021 Verification
Other Untaxed Income
185 Freedlander Drive | Clyde, NC 28721 | 828.627.4756 or 1.866.GoToHCC | fax: 828.627.4513 | hccaid@haywood.edu
7. 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 2018. Include support from a parent whose
information was not reported on the student’s 2020-2021 FAFSA, 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. 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
Source
Amount Received in 2018
Total Amount Received
$
8. Additional information:
Please provide 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 or
other forms submitted to the FAO, and include such things as federal veterans’ education benefits, military housing,
TANF, etc.
Name of Recipient Type of Financial Support
Amount of Financial Support
Received in 2018
Total Amount of Financial Support Received
$
Comments: ___________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
9. CERTIFICATION & SIGNATURES:
If student is classified as dependent, the student and parent whose information was reported on the FAFSA must sign and date.
Each person signing below certifies that all of the information reported is complete and correct.
_______________________________________________ ______________________
Print Student Name HCC ID # or SSN (last 4 digits)
_______________________________________________ ______________________
Student Signature Date
_______________________________________________ ______________________
Parent Signature (if dependent) Date
WARNING! If you purposely give false or misleading information, you may be fined, imprisoned, or both.
Note: Please allow four weeks for processing.
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