Clarificaon of Income
Dependent Student
Please provide informaon about any income received by the parent and any members of their household. This
may include items that were not required to be reported on the FAFSA®. Please use the table below to report
annual amounts received during the 2017 year. If the answer is zero or the queson does not apply to you, enter
Clarificaon of income for the calendar year ending December 31, 2017
Student name (print clearly) COCC ID number
* * If the answer is zero or the queson does not apply to you, enter 0 * * Parent(s)
Educaon credits (American Opportunity Tax and Lifeme Learning Tax Cred-
it) from IRS Form 1040-line 50 or 1040A-line 33 $ $
Child support paid because of divorce or separaon or as a result of a legal
requirement. Do not include support for children in your household.
$ $
Earnings from work under a cooperave educaon program offered by a col-
$ $
Taxable earnings from need-based employment programs, such as Federal
Work-Study, and need-based employment porons of fellowships and assis-
tantships. $ $
Taxable college grant and scholarship aid reported to the IRS as income. In-
cludes AmeriCorps benefits (awards, living allowances, and interest accrual
payments), as well as grant or scholarship porons of fellowships and assis-
tantships. $ $
Combat pay or special combat pay. Only enter the amount that was taxable
and included in the adjusted gross income. Do not enter untaxed combat pay
reported on the W-2 (Box 12, Code Q). $ $
Payments to tax-deferred pension and rerement savings plans (paid directly
or withheld from earnings) including, but not limited to, amounts reported on
the W-2 Form in Boxes 12a through 12d, codes D, E, F, G, H, and S. Do not
include amounts reported as DD. $ $
Financial Aid Office
541.383.7260 • fax: 541.383.7506
2600 NW College Way, Bend, Oregon 97703 • e-mail:
By signing this form, I cerfy the informaon reported is true and accurate. The student and parent must sign
and date. Adobe or signature type fonts will not be accepted.
Student signature Date Parent signature
Reviewer use only
* * If the answer is zero or the queson does not apply to you, enter 0 * * Parent(s) Student
IRA deducons and payments to self-employed SEP, SIMPLE, Keogh and other
qualified plans from IRS Form 1040-line 28 + line 32 or 1040A-line 17. $ $
Child support that you received for all children. Do not include foster care pay-
ments, adopon payments, or any amount that was court-ordered but not actu-
ally paid. $ $
Tax exempt interest income from IRS Form 1040-line 8b or 1040A-line 8b. $ $
Untaxed porons of IRA distribuons from IRS Form 1040-lines (15a minus 15b)
or 1040A-lines (11a minus 11b). Exclude rollovers. If negave, enter zero. $ $
Untaxed porons of pensions from IRS Form 1040-lines (16a minus 16b) or
1040A-lines (12a minus 12b). Exclude rollovers. If negave, enter zero. $ $
Other untaxed income not reported, such as workers’ compensaon, disability,
Black Lung Benefits, untaxed porons of health saving accounts from 1040-line
25, Railroad Rerement Benefits, etc.
Do not include extended foster care benets, student aid, earned income cred-
it, addional child tax credit, welfare payments, untaxed Social Security benefits,
Supplemental Security Income, Workforce Innovaon and Opportunity Act edu-
caonal benefits, on-base military housing or a military housing allowance, com-
bat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), for-
eign income exclusion or credit for federal tax on special fuels. $ $
Housing, food and other living allowances paid to members of the military, cler-
gy, and others (including cash payments and cash value of benefits). Do not in
clude the value of on-based military housing or the value of a basic military al-
lowance for housing. $ $
Veterans non-educaon benefits such as Disability, Death Pension, or Dependen-
cy & Indemnity Compensaon (DIC) and/or VA Educaonal Work-Study allowanc-
es. $ $
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 or other person
whose financial informaon is not reported on this form and that is not part of a
legal child support agreement. $ N / A $