Untaxed Income Statement
Office of Financial Aid ▪ 100 East 8
Street ▪ PO Box 9000 ▪ Holland, MI 49422-9000
P: 616-395-7765 ▪ F: 616-395-7160 ▪ email@example.com ▪ hope.edu/financialaid
Complete the following to verify any untaxed income your family received during 2018.
DON’T INCLUDE THE FOLLOWING UNTAXED INCOME TYPES:
Student financial aid, Workforce Investment Act educational benefits, benefits from flexible spending arrangements
(e.g. cafeteria plans), and combat pay if you are not a tax filer.
Untaxed Social Security benefits received for all household members (including the
untaxed portion of Social Security benefits reported on parents’ IRS Form 1040-
Untaxed SSI disability benefits received for ALL household members
Welfare benefits (including TANF). Do not include food stamps or subsidized
Child support received for all children. Do not include foster care or adoption
Foreign income exclusion (IRS Form 2555-line 45/Schedule 1-line 21)
Payments to tax-deferred pension and retirement plans in 2018, 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. DO NOT include amounts reported in code DD (health benefits)
Housing, food, and other living allowances paid to members of the military, clergy,
and others (including cash payments and cash value of benefits). Do not include the
value of on-base military housing or a military BAH.
Veterans’ non-education benefits such as Disability, Death Pension, Dependency &
Indemnity Compensation (DIC), &/or VA Educational Work Study allowances
Any other untaxed income or benefits. Describe source(s): ______________
Cash received or any money paid on your behalf and not reported elsewhere on this
form (Include support from family members not listed in your household,
as well as distributions from 529 plans not owned by you or your custodial parent/s.)
$________ $________ TOTALS
ARNING: If you purposely give false or misleading information, you may be fined, sent to prison, or
ach 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 this form. Return completed form to
the address listed below.
tudent Signature: ______________________________ Date Signed: ________________
Parent Signature: ______________________________ Date Signed: ________________