Household Resources Form
2018-19 Academic Year
Upon reviewing your 2018-19 FAFSA results, we must verify your reported household’s 2016 untaxed income. Please provide us with
the information requested below within 30 (thirty) days to finalize your eligibility for aid. Failure to comply may jeopardize your award
for the year.
Student’s Name Student ID#
Last First MI
Permanent Address
Street Address City State Zip
SSN (optional) ________________________ Home Phone ______________________ Cell Phone __________________
Student/Spouse
Calendar Year 2016
Parent(s)
$
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 Form in Boxes 12a
through 12d, codes D,E,F,G,H, and S. Don’t include amounts reported in code DD
(employer contributions toward employee health benefits).
(As relates to questions 45a and 94a on FAFSA)
$
$
Child support you received for all children in your household. Don’t include foster
care, adoption payments or any amount that was court ordered but not actually paid.
(As relates to questions 45c and 94c on FAFSA)
$
$
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.
(As relates to questions 45g and 94g on FAFSA)
$
$
Veterans’ non-education benefits received such as Disability, Death Pension, or
Dependency & Indemnity Compensation (DIC) and/or VA Educational Work-Study
allowances.
(As relates to questions 45h and 94h on FAFSA)
$
$
Other untaxed income not reported elsewhere on this form, such as workers’
compensation, disability, etc. Also include the untaxed portions of health savings
accounts from IRS Form 1040—line 25.
(As relates to questions 45i and 94i on FAFSA)
$
$
Money received or paid on your behalf (e.g., bills), not reported elsewhere on this
form.
(As relates to questions 45j on FAFSA)
XXXXXXXXXXXX
$
◄ TOTAL TOTAL ►
$
I (We) hereby affirm that all information reported on this form and any attachment hereto is true, complete, and accurate to the best of
my (our) knowledge. I (We) understand that if I (we) receive federal student aid based on incorrect information, I (we) will need to repay
it; I (we) may be required to pay fines and fees.
Student Date
Parent (if dependent) Date
Office of Financial Aid
300 College Park
Dayton, Ohio 45469-1605
937-229-4311
FAX: 937-229-4338
finaid@udayton.edu
www.finaid.udayton.edu
