University of Central Missouri
Office of Student Financial Services
P.O. Box 800
Warrensburg, MO 64093-5178
Phone 660-543-8266
FAX 660-543-8080
Parent(s) Untaxed
Income and Benefits
Office use only
Parent_Untaxed_18.pdf NOV 3, 2017
____________________________________________ 700_______________________________
Student's Name (please print) UCM ID Number
In accordance with federal regulations, the UCM Office of Student Financial Services is required to
verify certain responses to the following questions. Indicate below the total amount your parent(s)
received during the 12-month 2016 calendar year (January through December) for each of the
following programs. List yearly (not monthly) amounts:
Total Amount
for 2016 Year
Child support your parent(s) received for you and their other dependent
children. Don’t include foster care or adoption payments
Housing, food, and other living allowances paid to your parent as a member of
the military or clergy. Include cash payments and cash value of benefits, but
don’t include the value of on-base military housing/basic military allowance
for housing
Payments to tax-deferred pension and savings plans (paid directly or withheld
from earnings). Include amounts reported on your parent(s)’ 2016 W-2
forms (boxes 12a through 12d, codes D,E, F, G, H, and S
Veteran non-education benefits (Death Pension, Disability, Dependency and
Indemnity Compensation) and VA Educational Work-Study allowances
Workers' Compensation and Workers’ Disability payments
Life Insurance proceeds received in the 2016 calendar year
All other untaxed income and benefits for 2016. Don’t include any financial aid
or scholarships, your Earned Income Credit, welfare payments, untaxed Social
Security Benefits, combat pay, Supplemental Security Income, or food stamps
Additional clarification?
______________________________________________________ _________________________
Parent’s Signature Date
______________________________________________________ ________________________
Student’s Signature Date
Complete and submit this document to the UCM Office of Student Financial Services in person (1100 Ward Edwards
Bldg.) or by mail (Student Financial Services, P.O. Box 800, Warrensburg MO 64093-5178), or by fax (660-543-8080).
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