2021-2022 Independent Student Support Form
Student’s SSN or ID Number
Please Note: This form asks for amounts from two different years. The other untaxed income and child support
received uses 2018 information. The additional financial support uses 2019 information.
Other Untaxed Income
Answer each question below as it applies to the student and the student’s spouse (if married).
If any Item does not apply enter “N/A” for Not applicable where a response is requested or enter 0 (zero) if 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 student and spouse 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.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
Name of Person Who had Untaxed Income
Type of Untaxed Income Received in 2018
in 2017 for 2018 for 2018
Money received or paid on the students
Payments to tax-deferred pension and
Housing, food, and other living allowances
paid to members of the military, clergy
Veterans noneducation benefits
Money received or paid on the students
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 2018 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
Support in 2017 Received in 2018 Received in 2018
Total Amount of Child Support Received
1
Office of Financial Aid~ Louisiana College
1140 College Drive ~ LC Box 582 Pineville, La. 71359
Ph: 318-487-7386 Fax: 318-487-7449 email - financial_aid@lacollege.edu
