2022-2023 Untaxed Income Verification

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Student Name

Student ID#

It takes a minimum of 5 to 10 days for all Verification forms and documentation to be reviewed.

Complete the information in the chart below with the amount of each 2020 Untaxed Income item as requested on the 2022-2023 FAFSA. If any item does not apply, write “0”. DO NOT Estimate figure.

To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in 2020, multiply that amount by the number of months in 2020 you received it. If you did not receive the same amount each month in 2020, add together the amounts you paid or received each month.

If you feel an explanation should accompany any of the reported amounts please write an explanation below.

2020 Untaxed Income - Parent(s) (Dependent Student Only)

2020 Untaxed Income - Parent
Payments to Tax-deferred pension and retirement savings plans* List any payments (direct or withheld from earnings) to tax-deferred pensions and retirement savings plans (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. Child support Received List the actual amount of any child support received in 2020 for the children in your household. Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid. Housing, food, and other living allowances paid to members of the military, clergy, and others Include cash payments and/or the cash value of benefits received. Do not include the value of on-base military housing or the value of a basic military allowance for housing Veterans non-education benefits List the total amount of veteran’s non-education benefits received in 2020. Include 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, Dependents Education Assistance Programs, VEAP Benefits, Post-9/11 GI Bill. Other untaxed income *List the amount of other untaxed income not reported elsewhere on this form. Include untaxed income such as Workers’ Compensation, Disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Schedule 1 line 12, Railroad Retirement Benefits, etc. IRA deductions and payments to self-employed SEP, SIMPLE and Keogh and other qualified plans from IRS Form Schedule 1 total of lines 15 + 19 Tax exempt interest income from IRS Form 1040 – line 2a Untaxed portions of IRA distributions form 1040 – (lines 4a + 4c) minus (line 4b + 4d) Excludes rollovers. If negative, enter a zero.

Payments to Tax-deferred pension and retirement savings plans*

*List any payments (direct or withheld from earnings) to tax-deferred pensions and retirement savings plans (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.

Child support Received*

*List the actual amount of any child support received in 2020 for the children in your household. Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid.

Housing, food, and other living allowances paid to members of the military, clergy, and others*

*Include cash payments and/or the cash value of benefits received. Do not include the value of on-base military housing or the value of a basic military allowance for housing

Veterans non-education benefits*

*List the total amount of veteran’s non-education benefits received in 2020. Include 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, Dependents Education Assistance Programs, VEAP Benefits, Post-9/11 GI Bill.

Other untaxed income*

*List the amount of other untaxed income not reported elsewhere on this form. Include untaxed income such as Workers’ Compensation, Disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Schedule 1 line 12, Railroad Retirement Benefits, etc.

IRA deductions and payments to self-employed SEP, SIMPLE and Keogh and other qualified plans from IRS Form Schedule 1 total of lines 15 + 19

Tax exempt interest income from IRS Form 1040 – line 2a

Untaxed portions of IRA distributions form 1040 – (lines 4a + 4c) minus (line 4b + 4d) Excludes rollovers. If negative, enter a zero.

Student (and spouse, if married)

2020 Untaxed Income - Student
Payments to Tax-deferred pension and retirement savings plans* List any payments (direct or withheld from earnings) to tax-deferred pensions and retirement savings plans (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. Child support Received List the actual amount of any child support received in 2020 for the children in your household. Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid. Housing, food, and other living allowances paid to members of the military, clergy, and others Include cash payments and/or the cash value of benefits received. Do not include the value of on-base military housing or the value of a basic military allowance for housing Veterans non-education benefits List the total amount of veteran’s non-education benefits received in 2020. Include 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, Dependents Education Assistance Programs, VEAP Benefits, Post-9/11 GI Bill. Other untaxed income List the amount of other untaxed income not reported elsewhere on this form. Include untaxed income such as Workers’ Compensation, Disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Schedule 1 line 12, Railroad Retirement Benefits, etc. IRA deductions and payments to self-employed SEP, SIMPLE and Keogh and other qualified plans from IRS Form Schedule 1 total of lines 15 + 19 Tax exempt interest income from IRS Form 1040 – line 2a Untaxed portions of IRA distributions form 1040 – (lines 4a + 4c) minus (line 4b + 4d) Excludes rollovers. If negative, enter a zero. Money received or paid on the student’s behalf *Money received or paid on your behalf (e.g. bills) not reported elsewhere on this form. This includes money that your received from a parent whose financial information is not reported on this form and that is not part of a legal child support agreement

Payments to Tax-deferred pension and retirement savings plans*

Child support Received*

Housing, food, and other living allowances paid to members of the military, clergy, and others*

*Include cash payments and/or the cash value of benefits received. Do not include the value of on-base military housing or the value of a basic military allowance for housing

Veterans non-education benefits*

Other untaxed income*

IRA deductions and payments to self-employed SEP, SIMPLE and Keogh and other qualified plans from IRS Form Schedule 1 total of lines 15 + 19

Tax exempt interest income from IRS Form 1040 – line 2a

Untaxed portions of IRA distributions form 1040 – (lines 4a + 4c) minus (line 4b + 4d) Excludes rollovers. If negative, enter a zero.

Money received or paid on the student’s behalf*

*Money received or paid on your behalf (e.g. bills) not reported elsewhere on this form. This includes money that your received from a parent whose financial information is not reported on this form and that is not part of a legal child support agreement

2020 Additional Financial Information Parent

2020 Additional Financial Information Parent
Education Credits (American Opportunity, Hope and Lifetime Learning Tax Credits) IRS Form Schedule 3 – line 3 Child support you PAID because of divorce or separation as the result of a legal requirement (only include amount paid in 2020) Taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and assistantships Taxable College grant and scholarship aid reported to the IRS in the adjusted gross income. Includes AmeriCorps benefits (awards, living allowances and interest accrual payments) as well as grant or scholarship portions of fellowships and assistantships Combat pay or special combat pay (Only enter amount that was taxable and included in the AGI). Do not enter untaxed combat pay reported on the W-2 (box 12 Code Q) Earnings from work under a cooperative education program offered by a college

Education Credits (American Opportunity, Hope and Lifetime Learning Tax Credits) IRS Form Schedule 3 – line 3

Child support you PAID because of divorce or separation as the result of a legal requirement (only include amount paid in 2020)

Taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and assistantships

Taxable College grant and scholarship aid reported to the IRS in the adjusted gross income. Includes AmeriCorps benefits (awards, living allowances and interest accrual payments) as well as grant or scholarship portions of fellowships and assistantships

Combat pay or special combat pay (Only enter amount that was taxable and included in the AGI). Do not enter untaxed combat pay reported on the W-2 (box 12 Code Q)

Earnings from work under a cooperative education program offered by a college

2020 Additional Financial Information Student

2020 Additional Financial Information Student
Education Credits (American Opportunity, Hope and Lifetime Learning Tax Credits) IRS Form Schedule 3 – line 3 Child support you PAID because of divorce or separation as the result of a legal requirement (only include amount paid in 2020) Taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and assistantships Taxable College grant and scholarship aid reported to the IRS in the adjusted gross income. Includes AmeriCorps benefits (awards, living allowances and interest accrual payments) as well as grant or scholarship portions of fellowships and assistantships Combat pay or special combat pay (Only enter amount that was taxable and included in the AGI). Do not enter untaxed combat pay reported on the W-2 (box 12 Code Q) Earnings from work under a cooperative education program offered by a college

Education Credits (American Opportunity, Hope and Lifetime Learning Tax Credits) IRS Form Schedule 3 – line 3

Child support you PAID because of divorce or separation as the result of a legal requirement (only include amount paid in 2020)

Taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and assistantships

Combat pay or special combat pay (Only enter amount that was taxable and included in the AGI). Do not enter untaxed combat pay reported on the W-2 (box 12 Code Q)

Earnings from work under a cooperative education program offered by a college

Explanation, if needed:

Student Signature

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Date

Parent Signature (Dependent Student Only)

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Date

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