Financial Aid Office • SUNY Plattsburgh • 101 Broad Street • Plattsburgh, NY 12901-2681
Tel: (518) 564-2072 • Toll-Free: (877) 768-5976 • Fax: (518) 564-4079 • email: firstname.lastname@example.org
Revised: 12/01/2019 WRKSHD/I
ADDITIONAL FINANCIAL INFORMATION FOR 2020-2021
Student Name: ___________________________ Banner ID or NetID: ____________________________
In the table below, report the amounts for each item for the entire 2018 calendar year: January 1, 2018 to
December 31, 2018. Leave no spaces blank, enter zeros when appropriate.
Payments to tax-deferred pension and 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
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
Child support received for any of your children. Don’t include foster care or adoption
Tax exempt interest income from IRS Form 1040-line 8b or 1040A-line 8b
Untaxed portions of IRA distributions from IRS Form 1040-lines (15a minus 15b) or 1040A-
lines (11a minus 11b). Exclude rollovers. If negative, enter zero
Untaxed portions of pensions from IRS Form 1040 – lines (16a minus 16b) or 1040A – lines
(12a minus 12b). Exclude rollovers. If negative, enter zero.
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.
Veterans’ non-education benefits such as Disability, Death Pension, or Dependency &
Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.
Other untaxed income not reported, such as workers’ compensation, disability, etc.
Don’t include student aid, earned income credit, additional child tax credit, welfare payments,
untaxed Social Security benefits, Supplemental Security Income, Workforce Investment 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
Money received, or paid on your behalf )(e.g. bills), not reported elsewhere on this form
Additional Financial Information
Education Credits (American Opportunity, Hope and Lifetime Learning tax credits) from IRS
Form 1040-line 49 or 1040A-line 31
Child support paid because of divorce or separation or as a result of a legal requirement.
Don’t include support for children in your household
Taxable earnings from need-based employment programs, such as Federal Work-Study and
need-based employment portions of fellowships and assistantships
Taxable student grant and scholarship aid reported to the IRS in your adjusted gross income.
Includes AmeriCorps benefits (awards, living allowances and interest accrual payments), as
well as grant and scholarship portions of fellowships and assistantships
Combat pay or special combat pay. Only enter the amount that was taxable and included in
your adjusted gross income. Do not enter untaxed combat pay.
Earnings from work under a cooperative education program offered by a college.
By signing this worksheet I certify that all the information reported is complete and accurate. If false or
misleading information is purposely provided on this worksheet or the FAFSA I understand I may be fined,
sentenced to jail, or both.
Student Ink Signature Date
Parent Ink Signature If Dependent Date