401
Student Untaxed Income
Student Name: ______________________________ Student ID: _______________________
Please confirm the amounts from 2017 of the following items for the Student:
a. Payments to tax-deferred pension and retirement savings plans (paid directly or withheld from
earnings), including, but not limited to, amounts reported on the W-2 forms in Boxes 12a through
12d, codes D, E, F, G, H and S. Don’t include amounts reported in code DD (employer contributions
toward employee health benefits)
$________________
b
. IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and other qualified plans
from IRS Form 1040—line 28 + line 32 or 1040A—line 17.
$________________
c. Child support received for any of your children. Don’t include foster care or adoption payments.
$________________
d. Tax exempt interest income from IRS Form 1040—line 8b or 1040A—line 8b.
$________________
e. Untaxed portions of IRA distributions from IRS Form 1040—lines (15a minus 15b) or 1040A—lines
(11a minus 11b). Exclude rollovers. If negative, enter a zero here.
$________________
f. Untaxed portions of pensions from IRS Form 1040—lines (16a minus 16b) or 1040A—lines (12a
m
inus 12b). Exclude rollovers. If negative, enter a zero here.
$________________
g. Housing, food and other living allowances paid to members of the military, clergy and others
(including cash payments and cash value of benefits). Don’t include the value of on-base military
housing or the value of a basic military allowance for housing
$________________
h. Veterans non-education benefits, such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC) and/or VA Educational Work-Study allowances
$________________
