– Award Year
 Untaxed Income Form for Independent Students





  Student Income
Indicate if student (and/or spouse, if married) received any of the following benefits in . (ALL items MUST be answered.)

A. Payments to tax-deferred pension and retirement savings
List any payments to tax-deferred pension and savings plans. Include amounts reported on the W-2 form(s) in boxes 12a through 12d, codes D, E, F, G, H, and S.

The student, (and/or spouse, if married) did not make any payments to tax-deferred pension and retirement savings plans in  . 

The student, (and/or spouse, if married) made payments to tax-deferred pension and retirement savings plans in  . 

 



B. Child Support Received
List the actual amount of any child support received in  for the children in your household.

Do not include foster care payments or adoption payments.

The student, (and/or spouse, if married) did not receive any child support in .

The student, (and/or spouse, if married) received child support in .

 




C. Housing, food, and other living allowances paid to memebers 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.

The student, (and/or spouse, if married) did not receive living allowances in . 

The student, (and/or spouse, if married) received living allowances in . 

 




D. Untaxed Veterans Non-Education Benefits
List the total amount of veterans non-education benefits received in . Include Disability, Death Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances.

Do NOT include benefits reported on the IRS Tax Form.

The student, (and/or spouse, if married) did not receive Veterans Non-Education benefits in . 

The student, (and/or spouse, if married) received Veterans Non-Education benefits in . 

 




E. Any Other Untaxed Income
List the amount of other untaxed income not reported elsewhere on this form such as Worker’s Compensation, disability, etc.

Do NOT include student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels.

The student, (and/or spouse, if married) did not receive other untaxed income in . 

The student, (and/or spouse, if married) received other untaxed income in . 

 




F. Cash received or any money paid on the student’s behalf
List any money received or paid on the student’s behalf (e.g., payment of student’s bills) and not reported elsewhere on this form.

The student, (and/or spouse, if married) did not receive any additional money on their behalf in . 

The student, (and/or spouse, if married) received additional money on their behalf in . 

 





By listing my name below and submitting this electronic form I certify all the information reported is complete and correct. I also confirm the named person listed below executed this document in its entirety.