11/2016
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 2015
F. Money received or paid on the student’s behalf
List any money received or paid on the student’s (and spouse’s, if applicable) behalf (e.g., payment of a bill) not reported elsewhere on this form.
Purpose (e.g., cash, rent, books,
cell phone bill, car insurance, etc.)
Source of payment
Total amount
received in 2015
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, Medicaid, TANF, WIC, Supplemental Security Income, etc.
Name of recipient
Type of Benefit (e.g., veterans, military,
low-income, Medicaid, WIC, SSI, etc.)
Total amount
received in 2015
Please explain IN DETAIL how your family supported itself in 2015. Because FAFSA information requires 2015 income information
which may not reflect your current situation, please also explain IN DETAIL how your family is supporting itself now, including any
changes in employment, benefits, or other income from 2015. You may attach a separate sheet if needed.
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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 in the College Catalog and on the EWC website. 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 spouse (if applicable) must sign:
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Student’s signature Date Spouse’s signature Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
CERTIFICATIONS AND SIGNATURES
