Veteran’s Non-Educational Benefits:
List the total amount of veteran’s non-education benefits received in 2013. 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 2013? YES / NO (circle one)
If yes:
Name of recipient?
Type of benefit received?
Amount of benefit received in 2013? $
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 2013? YES / NO (circle one)
If yes:
Name of recipient?
Type of other income received?
Amount of other income received 2013? $
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 2013.Include support from a parent whose
information was not reported on the student’s 2014-2015 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 2014-2015 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 2013? YES / NO (circle one)
If yes:
Name of recipient?
Type of other income received?
Amount of other income received 2013? $
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 2013?
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
