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)
. IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and other qualified plans
from IRS Form 1040line 28 + line 32 or 1040Aline 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 1040line 8b or 1040Aline 8b.
e. Untaxed portions of IRA distributions from IRS Form 1040lines (15a minus 15b) or 1040Alines
(11a minus 11b). Exclude rollovers. If negative, enter a zero here.
f. Untaxed portions of pensions from IRS Form 1040lines (16a minus 16b) or 1040Alines (12a
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
i. Other untaxed income not reported in items a through h, such as workers’ compensation,
disability benefits, etc. Also include the untaxed portions of health savings accounts from IRS
Form 1040line 25. Don’t include extended foster care benefits, student aid, earned income
credit, additional child tax credit, welfare payments, untaxed Social Security benefits,
Supplemental Security Income, Workforce Innovation and Opportunity Act 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
j. Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form. This
includes money that you received from a parent or other person whose financial information is
not reported on this form and that is not part of a legal child support agreement.
By signing below, I certify that all of the information provided above is true and accurate to the best of
my knowledge. I acknowledge that if I purposefully falsify information on any financial aid document, I
may be subject to a fine, prison, or both.
Signature: ________________________________ Date: ___________________