STUDENT INFORMATION
UNTAXED INCOME INFORMATION
Mail: Financial Aid Office
Eastern Wyoming College
3200 West C Street
Torrington, WY 82240
Fax: 307-532-8222
2014-2015
Independent V6 Worksheet
Untaxed Income Verification
Students selected for verification of untaxed income (V6) must also complete the Standard Verification (V1)
Worksheet and MUST provide copies of all 2013 W-2 forms for student and spouse (if applicable) in order for the
verification process to be complete.
You and your spouse (if applicable) must complete and sign this worksheet, attach all required documents (including ALL 2013 W-2
forms) and submit to the Financial Aid Office at EWC.
______________________________________________________________ ________________________________________
Last Name First Name M.I. EWC Student ID Number
Fill in the information below as it applies to the student AND the student’s spouse (if applicable). DO NOT LEAVE ANY ITEM
BLANK. If any item does not apply, enter “N/A” for Not Applicable where a response is requested, or enter $0 in an area where an
amount is requested.
ALL AMOUNTS ARE ANNUAL. To determine the correct annual amount for each item: If you paid or received the same dollar
amount every month in 2013, multiply that amount by the number of months in 2013 you paid or received it. If you did not pay or
receive the same amount each month in 2013, add together the amounts you paid or received each month.
If more space is needed for any item, attach a separate page with student’s name, ID # and appropriate information.
A. Payments to tax-deferred pension and retirement savings
List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings plans, including, but not limited to,
amounts reported on W-2 forms (Boxes 12a through 12d with codes D, E, F, G, H, and S). Copies of all W-2 forms must be attached
.
Name of person who made payment
Total amount paid in 2013
Self
B. Child support received
List the actual amount of any child support RECEIVED in 2013 for any children listed on the Standard Verification (V1) worksheet as
a household member?
Name of adult who received
the child support payment
Name of child for whom
child support was paid
C. Housing, food, and other living allowances paid to members of the military, clergy, and others
Include cash payments and/or the cash value of benefits received.
Name of recipient Type of benefit received
Created 12/16/13
Over
CERTIFICATIONS AND SIGNATURES
INDEPENDENT
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
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
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. 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 a grandparent, aunt or uncle of the student.
Purpose (e.g., cash, rent, books,
cell phone bill, car insurance, etc.)
Source of payment (e.g., person
paying bill.)
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.)
Additional explanation of how your family supported itself in 2013: _____________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
By signing this worksheet, I/we certify that all of the information reported is complete and correct. I/we also acknowledge that I/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 spouse (if applicable) must sign:
________________________________________________ _______________________________________________
Student’s signature Date Spouses signature Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
click to sign
signature
click to edit
click to sign
signature
click to edit