If this document is not accessible, contact Disability Services at 910.788.6327, disabilityservices@sccnc.edu, or in A-124.
SOUTHEASTERN COMMUNITY COLLEGE
FINANCIAL AID OFFICE
2020-2021 DEPENDENT STUDENT VERIFICATION OF OTHER UNTAXED INCOME WORKSHEET
Your 2020-2021 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says
that before awarding Federal Student Aid, we may ask you to confirm the information you reported on your FAFSA. To verify that you
provided correct information, we will require certain information to be provided to the school. You must complete and sign this worksheet,
and submit the form and other required documents to the school. We may ask for additional information. If you have questions about
verification, contact the Financial Aid Office as soon as possible so that your financial aid will not be delayed.
STUDENT’S NAME: ________________________________________Student’s ID or SSN: ________________________
You should answer each question below as it applies to the student and the student’s parents whose information is on the FAFSA. 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
To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in 2018, multiply
that amount by the number of months in 2018 you paid or received it. If you did not pay or receive the same amount each month in
2018, add together the amounts you paid or received each month. If more space is needed, provide a separate page with the student’s
name and ID number at the top.
A. Payments to tax-deferred pension and retirement savings by student or parent:
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.
Name of Person Who Made the Payment Total Amount Paid in 2018
B. Child support received by parent:
List the actual amount of any child support received in 2018 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 Received
Amount of Child Support
Received in 2018
C. Housing, food, and other living allowances paid to student’s parents who are 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 of Benefit Received
in 2018
D. Veterans non-education benefits received by student or parent:
List the total amount of veterans non-education benefits received in 2018. 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
Amount of Benefit Received
in 2018
PLEASE COMPLETE REVERSE SIDE
If this document is not accessible, contact Disability Services at 910.788.6327, disabilityservices@sccnc.edu, or in A-124.
E. Other untaxed income received by student or parent:
List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include untaxed income such as
workers’ compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Line 25,
Railroad Retirement Benefits, etc.
Do not include any items reported or excluded in A – D above. In addition, 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
Amount of Other Untaxed
Income Received in 2018
F. Money received or paid on the student’s or parents’ behalf:
List any money received or paid on the student’s or parents’ behalf (e.g., payment of bills such as rent, utility bills, etc.) and not
reported elsewhere on this form. Enter the total amount of cash support received in 2018. For example, if someone is paying rent,
utility bills, etc., for the student’s parent or provides cash, gift cards, etc., include the amount of that person's contributions. Do not
include as student’s untaxed income any support from a parent whose information was reported on the 2020-2021 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 student’s parents, such as grandparents, aunts, and uncles of the student.
Purpose: e.g., Cash, Rent, Books Amount Received in 2018 Source
Additional information:
So that we can 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 parents or 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, SNAP, TANF, etc.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
Name of Recipient
Type of
Financial Support
Amount of Financial Support
Received in 2018
Comments:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Certification and Signature
I certify that all of the information reported on this worksheet is
complete and correct. The student must sign this worksheet.
____________________________________________________________
Student’s Signature and Date
____________________________________________________________
Parent’s Signature and Date
WARNING: If
y
ou
p
ur
p
osel
y
g
ive false or misleadin
g
information on this worksheet
,
y
ou ma
y
be fined
,
be sentenced to
j
ail
,
or both.
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