Untaxed Income 2012-2013

This form collects income that is untaxed by the IRS.

Please complete the worksheet below using 2011 tax year information

1. Tax-deferred pension and savings

   Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including, but not limited to ,amounts reported on the W-2 forms in Boxes 12a through 12d, codes D, E, F, G, H, and S

   Student/Spouse $ Parent $
2. IRA deductions

   IRA deductions and payments to self-employed SEP, SIMPLE, and Keogh and other qualified plans from IRS Form 1040-line 28+ line 32 or 1040A-line 17

   Student/Spouse $ Parent $
3. Child support

   Child support received for all children. Don’t included foster care or adoption payments.

   Student/Spouse $ Parent $
4. Tax exempt interest

   Tax exempt interest income from IRS Form 1040-line 8b or 1040A-line 8b.

   Student/Spouse $ Parent $
5. Untaxed portions of IRA distributions

   Untaxed portions of IRA distributions from IRS Form 1040–lines (15a minus 15b) or 1040A-lines (11a minus 11b). Exclude rollovers. If negative, enter a zero here.

   Student/Spouse $ Parent $
6. Untaxed portions of pensions

   Untaxed portions of pensions from IRS Form 1040-lines (16a minus 16b) or 1040A-lines (12a minus 12b). Exclude rollovers. If negative, enter a zero here.

   Student/Spouse $ Parent $
7. Living allowances

   Housing, food, and other living allowances paid to members of the military, clergy, and others (including cash payments and cash value of benefits). Don’t include the value of on-base military housing or the value of a basic military allowance for housing.

   Student/Spouse $ Parent $
8. Veterans non-education benefits

   Veterans non-education benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances.

   Student/Spouse $ Parent $
9. Other untaxed income

   Other untaxed income not reported, such as workers’ compensation, disability, etc. Also include the first-time homebuyer tax credit from IRS Form 1040-line 67. Don’t include student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social Security benefits, Supplemental Security Income, Workforce Investment Act educational benefits, on-base military housing or a military housing allowance, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion or credit for federal tax on special fuels.

   Student/Spouse $ Parent $
Name:
10. Money received, or paid on your behalf

    Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form.

    Student/Spouse $ Parent $

If the amount of this worksheet differs from the amount listed on the FAFSA, you must provide documentation.

If any blank is unanswered this form will be rejected which will delay your Financial Aid.

I certify that the information on this form is true and correct by signing with either an original or electronic signature.

Student's Signature: ________________________________________ Date:

Parent's Signature: ________________________________________ Date: