Clarificaon of Income
Independent Student
Please provide informaon about any income received by you and any members of your household. This may
include items that were not required to be reported on the FAFSA®. Please use the table below to report annual
amounts during the 2017 year. If the answer is zero or the queson does not apply to you, enter 0.
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 * * Student Spouse
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-
lege. $ $
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. Adobe or signature type fonts will
not be accepted.
Student signature Date
Reviewer use only
* * If the answer is zero or the queson does not apply to you, enter 0 * * Student Spouse
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 benefits, 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
whosenancial informaon is not reported on this form and that is not part of a
legal child support agreement. $ $
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