FINANCIAL AID OFFICE
Other Untaxed Income
185 Freedlander Drive | Clyde, NC 28721 | 828.627.4756 or 1.866.GoToHCC | fax: 828.627.4513 | email@example.com
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
- 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
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