2016–2017 Verification Form
Other Untaxed Income
_______________________________________________ _____________________________________
Last Name
First Name
M.I.
MCC Student ID #
______________________________________________(______)_______________________________
Student’s E-mail
__________________________
Home Phone Number
__________________________
Date of Birth
You reported unusually low income on the FAFSA. Please complete the following questions regarding untaxed income as of the time you completed the
FAFSA. If you were required to provide parental information on the FAFSA, answer each question as it applies to you and your parent(s). If not, answer
each question as it applies to you (and spouse, if married). If your answer to a question is zero or not applicable, put “0” or “N/A” in the answer space.
Failure to report adequate income to demonstrate support will result in denial of your request for financial aid at MCC.
Don’t leave any blanks!
STUDENT
PARENT
I) 2015 UNTAXED INCOME RESOURCES: List Annual Amounts
(& Spouse if married)
(If dependent)
List any payments (direct or withheld from earnings) to tax-deferred pension 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.
List the actual amount of any child support received in 2015 for the children in your household. Do
$
$
not include Foster Care or adoption payments.
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.
List the total amount of veterans non-education benefits received in 2015. Include Disability, Death
Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study
$
$
allowances.
List the amount of other untaxed income not reported and not excluded 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 Line 25, Railroad Retirement Benefits, etc.
$
$
Do not include untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce
Investment Act (WIA) educational benefits.
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. Enter the total amount of cash support the student received in
$
$
2015. Include support from a parent whose information was not reported on the student’s 2016–
2017 FAFSA, but do not include support from a parent whose information was reported.
Source
Amount per Month
Amount per Month
II) Additional Support Explanation: List Monthly Amount
Example: SSI
$0
$ 1,500
Complete this section only if you (and spouse, if married) and parent(s) (if
dependent) total taxed and untaxed annual income reported is less than
70% of the poverty guidelines*. Please explain how you/your parents
met monthly expenses (like low income housing, SNAP benefits, cash aid,
Welfare benefits, Social Security benefits, VA Education benefits, etc.).
Continue on the back of this form if more space is needed.
*http://aspe.hhs.gov/poverty/15poverty.cfm#guidelines
Certification and Signatures
I certify that all of the information reported on this worksheet is complete and correct.
Dependent Student: Student and one parent must sign this worksheet.
Independent Student: The student must sign this worksheet.
___________________________________________________
Student’s Signature
Date
WARNING: If you purposely give false or misleading
information on this worksheet, you may be fined, be
sentenced to jail, or both.
___________________________________________________________
Parent’s Signature (if dependent student)
Date
Submit the completed worksheet to:
Or mail to:
Muskegon Community College
Muskegon Community College
Student Welcome Center
Attn: Financial Aid Office
Or FAX to:
221 S Quarterline Road
FAX: (231) 777-0475
Muskegon, MI 49442
You should make a copy of all documents submitted for your records
REV: 02/16
FAC16OUI