CERTIFICATIONS AND SIGNATURES
DEPENDENT
D. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2013. Include Disability, Death Pension, Dependency and
Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances. DO NOT include federal veterans educational
benefits such as: Montgomery GI Bill, Dependents Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill.
Name of recipient
Type of Veterans
non-education benefit received
Total amount of benefit
received in 2013
E. Other untaxed income
List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include items such as disability,
workers’ compensation, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Line 25, Railroad
Retirement Benefits, etc.
DO NOT include student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to
Needy Families (TANF), untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Investment Act (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.
Name of recipient
Type of other
untaxed income received
Total amount of other untaxed
income received in 2013
F. Money received or paid on the student’s behalf
List any money received or paid on the student’s behalf (e.g., payment of a bill) not reported elsewhere on this form. Include support
from a parent whose information was NOT on the student’s FAFSA, but DO NOT include information from a parent whose
information IS included on the FAFSA. Amounts paid on the student’s behalf also include any distributions to the student from a 529
plan owned by someone other than the student or student’s parents
, such as grandparent, aunts and uncles of the student.
Purpose (e.g., cash, rent, books,
cell phone bill, car insurance, etc.)
Source of payment (parent NOT on
FAFSA, grandparent, etc.)
Total amount received
received in 2013
G. Additional information
So that we may fully understand the student’s family’s financial situation, please provide below information about any other resources,
benefits, and other amounts received by the student and any members of the student’s household. This may include items that were not
required to be reported on the FAFSA or other forms submitted to the financial aid office, and include such things as federal veterans
education benefits, military housing, low-income housing, SNAP, TANF, WIC, Supplemental Security Income, etc.
Purpose (e.g., cash, rent, books,
cell phone bill, car insurance, etc.)
Source of payment (parent NOT on
FAFSA, grandparent, etc.)
Total amount received
received in 2013
Additional explanation of how your family supported itself in 2013: _____________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
By signing this worksheet, we certify that all of the information reported is complete and correct. We also acknowledge that we have
read and agree to comply with all verification policies as stated by EWC. Failure to submit information in a timely fashion may
result in the application being filed as inactive with no further consideration and no federal aid for the academic year. Student and
parent must sign:
________________________________________________ _______________________________________________
Student’s signature Date Parent’s signature Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
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