F19UNTXD
2019-2020 Dependent Untaxed Income Worksheet
Student Name: SMC ID#
ENTER 0 FOR ANY ITEMS THAT DO NOT APPLY. DO NOT LEAVE ANY FIELDS BLANK!
REPORT CALENDAR YEAR 2017 INCOME
STUDENT Calendar Year 2017 PARENT(S)
$
Payments to tax-deferred pension/retirement savings plans (paid directly or withheld from earnings),
including, but not limited to amounts on the W-2 Form in Box 12a-12d, codes D, E, F, G, H, and S.
$
$
Child support received for all children. Do not include foster care or adoption payments.
$
$
Housing, food, and other living allowances paid to members of the military, clergy, and others
(including cash payments and cash value of benefits). Do not include the value of on-base military
housing or the value of a basic military allowance for housing.
$
$
Veterans’ non-education benefits, such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC) and/or VA Educational Work-Study allowances. Do not include veterans
educational benefits such as: Montgomery GI Bill, Post-9/11 GI Bill
$
$
Any other untaxed income or benefits, not reported elsewhere on this worksheet, such as worker’s
compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS
Form 1040 Line 25, Railroad Retirement Benefits etc. DON’T INCLUDE extended foster care benefits,
student aid, Earned Income Credit, Additional Child Tax Credit, welfare payments, untaxed Social
Security benefits, Supplemental Security Income, Workforce Innovation and Opportunity Act
educational benefits, on-based military housing or a military housing allowance,
from flexible spending arrangements (e.g. cafeteria plans), foreign income exclusion, or credit for
federal tax on special fuels. Identify source(s) of untaxed income, if applicable:
Student Parent
$
$
Money received, or any money paid on your behalf, not reported elsewhere on this form. Include
support received from a parent whose information was not reported on the student’s 2019-20
DO NOT INCLUDE support from the parent(s) whose information was reported on the 2019-20
For example, if someone is paying the student’s rent or tuition bills or gives the student cash, report
the value of those contributions unless that person is the student’s parent whose information was
reported on the 2019-20 FAFSA. Also report distributions from a 529 plan if that plan is owned by
someone other than the student or parent whose information is reported on the 2019-20 FAFSA.
N/A
CERTIFICATION: I certify that all the information reported on this form is true, complete and correct. I understand that any false
statements could be cause for denial, reduction, withdrawal or repayment of financial aid.
Please print and sign before submitting. We CANNOT accept digital signatures.
Student Signature Date
Parent Signature Parent Printed Name Date
Office of Student Financial Services
One Winooski Park, Box 4
Colchester, VT 05439
Tel. 802-654-3243
Fax: 802-654-2591
