Office of Financial Aid
323 Erie Street, P.O. Box 5015, Port Huron, Michigan 48061-5015
810-989-5530 fax 810-989-5774 sc4.edu
4/9/2020
SC4 2020-2021 Income Worksheet
Name ____________________________________________Student ID (SSN) _________________
Phone _______________________________ Email _______________________________________
Use the lines below to report any additional or untaxed income your household received in 2018. Dependent students:
please answer the questions about both your parents and yourself.
Student
Parent
Additional Income
$
$
Child Support paid because of divorce or separation or as a result of a legal
requirement. Don’t include support for children in your household.
$
$
Taxable earnings from need-based employment programs, such as Federal Work-Study
and need-based employment portions of fellowships and assistantships.
$
$
Taxable college grant and scholarship aid reported to the IRS as income. Includes
Americorps benefits (awards, living allowances and interest accrual payments), as well
as grant and scholarship portions of fellowships and assistantships.
$
$
Combat pay or special combat pay. Only enter the amount that was taxable and
included in your adjusted gross income. Don’t include untaxed combat pay.
$
$
Earnings from work under a cooperative education program offered by a college.
Student
Parent
Untaxed Income
$
$
Payments to tax deferred pension and retirement savings plans (paid directly or
withheld from earnings), including, but not limited to, amounts reported on the W-2
forms in Boxes 12a through 12d, codes D, E, F, G, H and S. Don’t include amounts
reported in code DD (employer contributions toward employee health benefits).
$
$
Child support received for any of your children. Don’t 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). Don’t include the value of
on-base military housing or the value of a basic military allowance for housing.
$
$
Veteran’s non-education benefits, such as Disability, Death Pension, or
Dependency and Indemnity Compensation (DIC) and/or VA Educational Work-
Study allowances
$
$
Other untaxed income not reported above, such as workers’ compensation, disability,
etc. Also include the untaxed portions of health savings accounts from IRS Form 1040
Schedule 1 line 25. 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 Investment Act educational
benefits, on-base military housing or a military housing allowance, combat pay, benefits
from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion or
credit for federal tax on special fuels.
$
$
Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this
form. This includes money that you received from a parent or other person whose
financial information is not reported on this form and that is not part of a legal child
support agreement.
Student ID:_______________
Rec’d by:_________________
Date:____________________
Office of Financial Aid
323 Erie Street, P.O. Box 5015, Port Huron, Michigan 48061-5015
810-989-5530 fax 810-989-5774 sc4.edu
4/9/2020
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. If requested, I agree
to provide additional documentation to the Financial Aid Office. Warning: If you purposely give false or misleading information on
this worksheet, you may be fined, be sentenced to jail, or both.
Student’s Signature __________________________________________ Date _____________________
Parent’s Signature ___________________________________________ Date _____________________
If you are able, please print and physically sign this form. If you do not have access to print, please type your name above, but you both will need to
come into the Financial Aid office once we re-open to sign.
Return this form to the SC4 Office of Financial Aid:
Fax: 810-989-5774 E-mail: financialaid@sc4.edu
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome