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
Student Untaxed
Income and Benefits
UCM use only
Student_Untaxed_18.pdf NOV 3 0,2017
______________________________________________ 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 you (and
your spouse, if married) 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 received for all your dependent children. Don’t include foster care
or adoption payments
Housing, food, and other living allowances paid to you and/or your spouse 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 2016 W-2 form (boxes
12a through 12d, codes D, E, F, G, H and S)
Veteran non-education benefits (Death Pension, Disability, and 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? ______________________________________________________________
_________________________________________________________ ______________________
Student’s Signature Date
_________________________________________________________ _____________________
Spouse’s Signature (if student is married) 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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