Fillable B. Untaxed Income Information (Virginia Western Community College)

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B. Untaxed Income Information (Virginia Western Community College)

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U 2021-2022 Parent Untaxed Income FormU
The U.S. Department of Education selected your student’s 2021-2022 FAFSA for review after comparing your 2019 Adjusted Gross
Income and other untaxed income. You and your spouse, if you are married, must complete form. You and your student must print, sign, and
submit the form. Instructions for submission are at the end of the form.
You and your spouse, if you are married, must complete this form. One parent and the student must sign and submit this form to
the Financial Aid Office to continue the verification review process.
B. Untaxed Income Information
Report total annual amounts for 2019. If an item does not apply, enter “0” or “N/A.” Boxes left blank will result in additional information requested. Additional
requests to clarify conflicting information may delay the determination of your student’s financial aid eligibility. If more space is needed provide a separate page
with your student’s name and student ID number at the top.
Untaxed Income Item to Verify:
Parent Name(s) for whom the information below is being reported (first and
last name(s)
Parent One:
Total 2019 Amount:
Parent Two:
(if Parent is married)
Total 2019 Amount:
Parent One Name:
Parent Two Name:
(If parent is married)
Payments made to tax-deferred pension and retirement savings plans. 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.
$
$
IRA Deductions & payments to self-employed SEP, SIMPLE, Keogh, and other qualified
plans. List the total amounts from IRS 1040 Schedule 1 – Total of lines 15 + 19.
$
$
Child Support Received. List actual amount received in 2019 for any children in your household. If additional space is needed attach
a separate piece of paper with required information. Do not include foster care payments, adoption payments, or court-order amounts
not actually paid. LIST NAME OF CHILD(REN):
Child’s Name:
$
$
Child’s Name:
$
$
Adult Receiving
Payment:
Untaxed Portions of IRA distributions and Pensions. List amount from IRS 1040 – (lines 4a
+ 4c) minus (4b +4d). Exclude Rollovers. If the value is negative enter ‘0’.
$
$
Tax exempt interest income. List amount from IRS 1040 – line 2a.
$
$
A. Student Information
First Name MI
VWCC Student ID - Required
First Name MI Last Name VWCC Student ID - Required
Untaxed Income Item to Verify - CONTINUED:
Parent One:
Total 2019 Amount:
Parent Two:
(if Parent is married)
Total 2019 Amount:
Housing, food, and other living allowances paid to members of the military, clergy, and
others. Include cash payments and cash value of benefits. UDo not includeU the value of on-base
military housing or the value of a basic military housing allowance (BAH).
$
$
Veteran’s non-education benefits. List the total 2019 amounts including disability, death pension, Dependency and Indemnity Compensation (DIC),
and/or VA Educational Work-Study allowances. UDo not includeU federal veterans’ educational benefits like the Montgomery GI Bill, Dependents Education
Assistance Program, VEAP Benefits, or the Post 9/11 GI Bill.
TYPE OF BENEFIT:
$
$
TYPE OF BENEFIT:
$
$
Other items not reported above. Include items such as worker’s compensation, disability, Black Lung Benefits, untaxed portions of health savings
accounts from IRS 1040 Schedule 1 -- Line 12, Railroad Retirement Benefits, etc. Do not include student aid, earn income credit, additional child tax
credit, TANF, SNAP, SSI, WIA, Educational benefits, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income
exclusion, or credit for federal tax on special fuels.
SOURCE:
$
$
SOURCE:
$
$
C. Certification and Signatures
The student and one parent for whom information is provided above MUST sign and date this section. Each person signing below certifies that all the
information reported on this form is complete, correct, and any additional information is attached, if necessary. WARNING: If you purposely give false
or misleading information on this worksheet you may be fined, sentenced to jail, or both.
______________________________________________________________________
_______________
Student Signature Required
Date
______________________________________________________________________
_______________
Parent Signature Required
Date
UWAYS TO SUBMIT THIS FORMU
1) Upload the form at Uwww.virginiawestern.comU 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 (Revised 10/2020)
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B. Untaxed Income Information (Virginia Western Community College)

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Completed 4 February 2021

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