2019–2020 Parent Untaxed Income Form
The Department of Education has requested that the Financial Aid Office verify certain information reported on your FAFSA.
BRCC is required by federal law to compare your FAFSA with the information on this worksheet. You, your parent, and parent’s
spouse if married, must complete this form. You and your parent must sign and submit the form to the Financial Aid Office to
determine eligibility for federal student aid. Incomplete forms or conflicting information will cause delays in the processing of your
aid. Instructions for looking up your Student I.D. can be found here.
A. Student Information
Last Name: _____________________________________ First Name: __________________________________________
Student ID (required): __________________Date of Birth: _________________ Phone Number: ______________________
B. Untaxed Income Information
Report total amounts received for the entire year of 2017. If an item does not apply use “0” or “N/A.”
C. Certification and Signatures
The student and the 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’s Signature: _________________________________________________ Date: ____________________
Parent’s Signature: __________________________________________________ Date: ____________________
Please return this completed form in one of the following ways: upload it using the link to the form on your To-Do list in SIS, fax to 540-234-
8189, scanned e-mail attachment to finaid@brcc.edu, or mail to Blue Ridge Community College, Office of Financial Aid, Box 80, One College
Lane, Weyers Cave, VA 24486. Please call 855-844-3631 if you have questions.
Parent(s) Total
2017 Amount:
Payments made to tax-deferred pension and retirement savings plans:
Includes payments to tax-deferred pension and retirement savings plans, direct or withheld from earnings.
Examples: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, Keough, and other qualified plans.
Amount found on IRS 1040: combine lines 28 and line 32 or IRS 1040A: line 17.
Child Support Received. List actual amount received in 2017 for any children in your household. Do not include foster
care payments, adoption payments, or court-order amounts not actually paid.
Parent receiving: _________________________________ for child/children: __________________________________
________________________________________________________________________________________________
Untaxed Portions of IRA distribution. Exclude Rollovers. If the value is negative enter ‘0’.
Amount found on IRS 1040: line 15a minus 15b or IRS 1040A: line 11a minus 11b.
Tax exempt interest income. Amount found on IRS 1040: line 8b or IRS 1040A: line 8b.
Untaxed Portions of Pension distribution. Exclude Rollovers. If the value is negative enter ‘0’.
Amount found on IRS 1040: line 16a minus 16b or IRS 1040A: line 12a minus 12b.
Housing, food, and other living allowances paid to members of the military, clergy, and others. Include cash payments and
cash value of benefits. Do not include the value of on-base military housing or basic military housing allowance (BAH)
Veteran’s non-education benefits. This includes disability, death pension, Dependency and Indemnity Compensation
(DIC), and/or VA Educational Work-Study allowances. Do not include 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: _____________________________________________________________________
Other items not reported above. Includes worker’s compensation, disability (not including SSDI), Black Lung Benefits,
untaxed portions of health savings accounts from IRS 1040: Line 25, 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.
RECIPIENT(s): __________________________________ SOURCE(s): _______________________________________
__________________________________ _______________________________________
