Fillable 2021-2022 Income Level Verification for 2019 (Virginia Western Community College)

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2021-2022 Income Level Verification for 2019 (Virginia Western Community College)

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Page 1 of 3
2021-2022 Income Level Verification for 2019
The U.S. Department of Education selected your student’s 2021-2022 FAFSA for review. You or your parent(s) reported
zero income on the FAFSA for 2019. You are required to complete this form for review of any untaxed income that may
have been used to support your or your parent’s household. Review the instructions below, complete the form
accordingly, and submit to the Financial Aid Office along with other required documentation.
First Name MI
Last Name
VWCC Student ID - REQUIRED
Select applicable statement and complete form accordingly:
I, the student, was required to provide parental
information on the
2021-2022 FAFSA. The
answers on this form reflect information for me
and/or my parents.
I, the student, was not required to provide
parental information on the
2021-2022 FAFSA.
The answers on this form reflect information
from me and/or my spouse, if married.
IMPORTANT INFORMATION:
• I
f any item does not apply, enter “N/A” for Not Applicable where a response is requested or enter 0 (zero) in an
a
rea where an amount is requested
.
• The amounts reported must be the Utotal yearly amountU.
A. Federal and other Benefits received in 2019 or 2020: Please select any of the benefits listed below or list any
other benefits that you or someone in your household received
.
Federal Benefits Received 2019 or 2020
Amount Received
Medicaid
Supplemental Security Income (SSI)
Free or Reduced-Price School Lunch
Temporary Assistance for Needy Families
(TANF)
Special Supplemental Nutrition Program for
Women, Infants and Children (WIC)
Other Benefits Received for 2019: List
each benefit
Name of Recipient Amount Received
B. 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 2019
Page 2 of 3
Student Name
Student ID
C. Child support received:
List the actual amount of any child support received in 2019 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 2019
D. 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 the value of a basic military allowance for housing.
Name of Recipient
Type of Benefit Received
Amount of Benefit Received in 2019
E. Veterans non-education benefits:
List the total amount of veterans non-education benefits received in 2019. Include Disability, Death Pension,
Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowance.
Do not include federal veterans 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-
education Benefit
Amount of Benefit
Received in 2019
F. 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 Schedule 1-- Line 12, Railroad Retirement Benefits, etc.
Do not include: any items reported or excluded in A – D above. In addition, do not include extended foster care benefits,
student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed
Social Security benefits, Supplemental Security Income (SSI), Workforce Innovation and Opportunity Act (WIOA)
educational benefits, on-base military housing or a military housing allowance, 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 2019
Page 3 of 3
Student Name Student ID
G. STUDENT ONLY: Money received or paid on the Ustudent’sU behalf:
List any money received or paid on the Ustudent’sU 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 2019. UInclude support fromU
Ua parent whose information was not reported on the student’s 2021-2022 FAFSUA. UDo not includeU 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 2021-2022 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
Amount Received by UstudentU in 2019
Source
SAMPLE Cell Phone Bill
$600.00
Father
Additional information:
So that we can fully understand the student’s family's financial situation, please provide below information about
any other financial support that was received for 2019 that has not already been listed. If more space is needed,
provide a separate page with the student’s name and ID number at the top.
Additional details: Please provide details of financial support for 2019 not reported in any other section of this form.
Certification and Signature: Each person signing this form certifies that all the information reported
here is complete and correct. The student must sign and date below. If the student is a dependent
student for the purpose of applying for Federal Student Aid, then the parent signature and date is also
required.
______________________________________________________________________
_______________
Student Signature Required
Date
______________________________________________________________________
_______________
Parent Signature Required
Date
UWAYS TO SUBMIT THIS FORMU
(1.) Upload the form at 30TUwww.virginiawestern.comU30T by clicking “Contact Us,’ and then clicking the 24/7 Student
Support icon. Once you log in you can submit documents (2) Fax forms to 540-857-6208 ♦Phone: (855)874-
6690 10/2020
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2021-2022 Income Level Verification for 2019 (Virginia Western Community College)

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Completed 4 February 2021

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