2021-2022 Dependent Student Support Form
Student’s Email Address
Student’s Phone Number
Student’s Date of Birth
Answer each question below as it applies to the student and the student’s parent(s) whose information is on the FAFSA.
If any Item does not apply enter “N/A” for Not Applicable where a response is requested or enter 0 (zero) in an area where an amount
is requested.
2019 IRS W-2 Forms: Copies of all 2019 IRS W-2 Forms issued by the employers to the dependent student and the student’s parents
must be provided.
To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in 2019 multiply
that amount by the number of months in 2019 you paid or received it. If you did not pay or receive the same amount each month
in 2019 add together the amounts you paid or received each month.
I
f more space is needed, provide a separate page with the student’s name and ID number at the top.
of Person Who had Untaxed
Student Amount Parent Amount
Income in 2019
Beatrice Jones (example)
Type of Untaxed Income Received in 2019
Money received or paid on the students behalf
Payments to tax-deferred pension and savings plans
Housing, food, and other living allowances paid
to members of the military, clergy
Veterans non-education benefits
Money received or paid on the students behalf
Other untaxed income
for 2019
for 2019
$500.00
0
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 2019 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 Received
Received
in 2019
Total Amount of Child Support Received $
Additional Financial Support
1
Office of Finanical Aid ~ Louisiana College
1140 College Drive ~ LC Box 582 Pineville, La. 71359
Ph: 318-487-7386 Fax: 318-487-7449 financial_aid@lacollege.edu
The information below is for the parents to complete with their income information
