Office of Student Financial Aid and Scholarships
P O Box 907
Normal, AL 35762
2016-2017 Verification of Untaxed Income Form
Name: _________________________________________________________________ ID#: _____________________________
Your 2016-2017 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The
law states that before awarding Federal Student Aid, we may ask you to confirm the information you (and your parents, if you
are a dependent student) reported on your FAFSA. To verify that you provided correct information the financial aid
administrator at your school will compare your FAFSA with the information on this worksheet and with any other required
documents. If there are differences, your FAFSA information may need to be corrected. You (and at least one parent, if you are
a dependent student) must complete and sign this worksheet and submit the form and other required documents to IDOC
College Board Processing Center. Your school may ask for additional information. If you have questions about verification,
contact your financial aid administrator as soon as possible so that your financial aid will not be delayed.
Student & Spouse Untaxed Income Source Parent(s)
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 for any 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.
Veterans’ noneducation benefits, such as Disability, Death Pension, or
Dependency & 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 – 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 whose financial
information is not reported on this form and that is not part of a legal child
support agreement.
Other (please explain):_____________________________________________________________________________________
________________________________________________________________________________________________________
As certified by the signatures below, all the information provided by myself and/or others is true and complete to the best of
my (our) knowledge. I/we understand that the Financial Aid Office may request additional documentation to verify the above
information. (Note: If you are a dependent student, you and a parent must sign this form; if you are married, you and your
spouse must sign.)
Student’s Signature: ___________________________________________________ Date: _______________________________
Student’s Spouse’s Signature: ___________________________________________ Date: _______________________________
Parent’s Signature: ____________________________________________________ Date: _______________________________
College Board Processing Center · PO Box 8570 · Portsmouth, NH 03802
