Financial Aid Office
202 S. Halsted St. (708) 709-3735
Chicago Heights, IL 60411 Fax: (708) 709-3716
2016-2017 VERIFICATION OF UNTAXED INCOME
STUDENT INFORMATION
Last Name First Name MI Student ID Number/Social Security Number
( )
Email Phone Number
Your 2016-2017 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification.
In order to process your financial aid for the 2016-2017 academic year, we need to gather additional information about you
and your parents as required by the U.S. Department of Education (34 CFR, Part 668).
FORM COMPLETION INSTRUCTIONS
Select Yes or No for each section and then complete the corresponding questions for those with a Yes response.
How to determine the correct annual amount for each item. If you paid or received the same dollar amount every
month in 2015, multiply that amount by the number of months in 2015 you paid or received it. If you did not pay or receive
the same amount each month in 2015, add together the amounts you paid or received each month.
If any item does not apply, enter “N/A” for Not Applicable where a response is requested, or enter 0 in an area when an
amount is requested.
If more space is needed, provide a separate page with the student’ name and ID number at the top.
Payments to tax-deferred pension and retirement plans:
List any payments (direct or withheld from earnings) to tax deferred pension and retirement savings plan (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. Include data for yourself and your parents.
Did you or your parent(s) make payments in 2015? YES / NO (circle one)
If yes:
Name of person who made payment?
Total amount paid in 2015? $
Child Support Received:
List the actual amount of child support received in 2015 for the children in the household. Do not include foster care
payments, adoption payments, or any amount that was court-ordered but not actually paid.
Did you or your parent(s) receive support in 2015? YES / NO (circle one)
If yes:
Name of adult who received the support?
Name of child for whom support was paid?
Amount of child support received in 2015? $
Housing, Food & Other Living Allowances Paid to Military, Clergy & Others:
Include cash payments and/or the case value of benefits received. Do not include the value of on-base military housing or
the value of basic military allowance for housing.
Did you or your parent(s) receive benefits in 2015? YES / NO (circle one)
If yes:
Name of recipient?
Type of benefit received?
Amount of benefit received in 2015? $
M:\StuServ\FAVAoffice\2016-17 Forms\Verificationofuntaxedincome.wpd
Veteran’s Non-Educational Benefits:
List the total amount of veteran’s non-education benefits received in 2015. Includes 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, Dependent’s Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill.
Did you or your parent(s) receive benefits in 2015? YES / NO (circle one)
If yes:
Name of recipient?
Type of benefit received?
Amount of benefit received in 2015? $
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 account from IRS Form
1040 Line 25, Railroad Retirement Benefits, etc.
Did you or your parent(s) receive benefits in 2015? YES / NO (circle one)
If yes:
Name of recipient?
Type of other income received?
Amount of other income received 2015? $
Money Received or Paid on the Student’s Behalf:
List the 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 2015. Include support from a parent whose
information was not reported on the student’s 2016-2017 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 give cash, gift cards,
etc., include the amount of that person’s contribution unless the person is the student’s parent whose information is
reported on the 2016-2017 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.
Did you or your parent(s) receive benefits in 2015? YES / NO (circle one)
If yes:
Name of recipient?
Type of other income received?
Amount of other income received 2015? $
Additional Information: So that we can fully understand the student’s family’s financial situation, please provide
information below about any other resources, benefits, and other amounts received by the student and any members of the
student’s household. Note: This may include items that were not required to be reported on the FAFSA, or other forms
submitted to the Office of Financial Aid, and includes 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 received in 2015?
CERTIFICATION & 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.
WARNING! If you purposely give false or misleading information you may be fined, be sentenced to jail, or both.
___________________________________________ _______________________________
Student Signature Date
___________________________________________ _______________________________
Parent Signature Date
click to sign
signature
click to edit