VUTI20
VERIFICATION OF UNTAXED INCOME FORM
(2019-2020 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA-111-Verification of Untaxed Income 1920 20181003
This form is used to verify the Untaxed Income reported on the FAFSA (Student question 45 and Parent question 94). In
general, these figures are not greater than the Adjusted Gross Income. Please confirm the amounts of the Untaxed
Income reported on the FAFSA. Independent Students do not need to include parental data.
Untaxed Income
Parent(s)
2017 Amount
(Dependent
Students
ONLY)
Student /
Spouse 2017
Amount
A
Payments to tax-deferred pension and retirement savings in 2017: 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.
$ $
B
IRA deductions and payments to self-employed SEP, SIMPLE Keogh and
other qualified plans. Reported on IRS Form 1040 on lines 28 + 32 or 1040A line 17.
$ $
C
Child support received in 2017: List the actual amount of any child support
received in 201 for the children in your household. Do not include foster care
payments, adoption payments, or any amount that was court-ordered but not actually
paid.
$ $
Tax exempt interest income. Reported on IRS Form 1040 line 8b or 1040A line 8b.
E
Untaxed portions of IRA distributions. Reported on IRS Form 1040 lines (15a
minus 15b) or 1040A lines (11a minus 11b). Exclude rollovers. If amount negative,
$ $
F
Untaxed portions of pensions. Reported on IRS Form 1040 lines (16a minus 16b)
or 1040A lines (12a minus 12b). Exclude rollovers. If amount negative, enter zero in
$ $
G
Housing, food, and living allowances paid to members of the military, clergy
received in 2017: Include cash payments and/or the cash value of benefits received.
Do not include the value of on-base military housing or the value of a basic military
$ $
H
Veteran’s non-education benefits received in 2017: Such as Disability, Death,
Pension, or Dependency & Indemnity Compensation (DIC) and/or VA Educational
$ $
I
Other untaxed income received in 2017: Such as
worker’s compensation, disability, Railroad Retirement Benefits, etc. Do not
include: welfare, social security, SSI, WIA educational benefits, financial aid or
$ $
J
Money received or paid on the student’s behalf.
List any money received or paid on the student’s behalf in 2017 (e.g., payment of
student’s bills) and not reported elsewhere on this form.
$ $
I(we) certify that information provided on this form is true and complete to the best of my knowledge. Purposely giving false or
misleading information may result in a delay or denial of my federal financial aid and I may be fined up to $20,000, sent to prison or
both. (Electronic Signatures are not accepted)
Student Date Parent (Required for dependent students) Date
@
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
