2014 Other Untaxed Income
On this form please document the reasons and amounts of Other Untaxed Income received or paid by the student (and the students parents, if
student is Dependent). 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. If additional space is required, please continue on the back of this form.
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 (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. Please provide copies of ALL W-2s.
Name of Person Who Made the Payment
Total Amount Paid in 2014
B. Child support received
List the actual amount of any child support received in 2014 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.
Name of Adult Who Received the Support
Name of Child For Whom Support Was
Amount Received in 2014
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. Do not include the value of on-base military housing or the value of a basic
military allowance for housing.
Name of Recipient
Type of Benefit Received
Amount Received in 2014
D. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2014. 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
E. Other untaxed income
List the amount of other untaxed income not reported elsewhere on this form. Include untaxed income such as workers compens ation, disability, Black
Lung benefits, untaxed portions of health savings accounts from IRS Form 1040 Line 25, Railroad benefits, etc. Do not include any items reported or
excluded in A D above, 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
Amount Received in 2014
F. Money received or paid on the student’s behalf
List any money received or paid on the student’s behalf (e.g., payment of students bills) and not reported elsewhere on this form. Enter the total
amount of support the student received in 2014. Include support from a parent whose information was not reported on the students 2015-2016
FAFSA. 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 the students parents , such as grandparents, aunts, and uncles of the student.
Purpose: e.g., Cash, Rent, Books
Amount Received in 2014
By signing this information request, I certify that all information is complete and correct. If you purposely give false or misleading information on this
worksheet, you may receive a fine, a prison sentence, or both.
Student’s Signature: Date:
Parent’s Signature:
(if Dependent Student)