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UNTAXED INCOME FORM
2018-2019
Financial Aid Office/Enrollment Services
452 South Anderson Road, Rock Hill, South Carolina 29730
Phone (803) 327-8008 Fax (803) 981-7278
Student Name CID
A review of your financial aid file has determined that the income reported on the FAFSA is insufficient to
provide basic average living expense (such as food, clothing, shelter and other necessities) based on your
household size. Unusually low income can sometimes indicate unreported financial resources.
All sections must be completed.
Dependent Students (Parents must complete)
Independent Students (Student must complete)
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.
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.
Name of Person Who Made the Payment
Total Amount Paid in 2016
Per year
Per year
B. Child support received
List the actual amount of any child support received in 2016 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
Amt. of Child Support
Received in 2016
Per year
Per year
Per year
Per year
Per year
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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 of Benefit
Received in 2016
Per year
Per year
Per year
D. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2016. 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
Amt. of Benefit
Received in 2016
Per year
Per year
Per year
E. Other untaxed income
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 2016
Per year
Per year
Per year
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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 student's bills) and not
reported elsewhere on this form. Enter the total amount of cash support the student received in
2016. Include support from a parent whose information was not reported on the student's 2018-
2019 FAFSA, but do not include support from a parent whose information was reported. For
example, if someone is paying rent, utility bills, etc., for the student or gives cash, gift cards, etc.,
include the amount of that person's contributions unless the person is the student's parent whose
information is reported on the student's 2018-2019 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
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 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.
Name of Recipient
Type of
Financial Support
Amount of Financial
Support Received in 2016
Per year
Per year
Per year
Per year
Per year
Per year
Comments:
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A. Certification and Signatures
Each person signing below certifies that all of the
information reported is complete and correct.
The student and one parent whose information was
reported on the FAFSA must sign and date.
Student’s Signature
Date
Parent’s Signature (for dependent students)
Date
WARNING: If you purposely give false or
misleading information you may be fined,
be sentenced to jail, or both.
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