*UNTXDC*
1516
*TRACKING REQUIREMENT*
2014 UNTAXED INCOME CERTIFICATION – INDEPENDENT (STUDENT/SPOUSE)
Student Name :
ID# W
(please print Last, First)
Beginning in 2014-2015, certain applicants will be required to verify the untaxed income information they provided on the FAFSA. If the
Financial Aid Office determines that the amounts provided and/or verified do not appear to provide sufficient financial support for the
number of household family members reported, the applicant and spouse/parents must explain how the family was financially supported
during the 2014 calendar year.
OR
Our review of your financial aid application indicates that your (and your spouse’s, if married) total income from all sources for 2014
appears to be unusually low or that you and/or your spouse were not going to file federal taxes. Complete this form, attach any
documentation requested and return to our office during business hours so we may work with you to establish your financial aid
eligibility.
 Attached is a signed photocopy of my/our 2014 federal
income tax return transcript.
 I/We did not file, and am/are not required to file, a 2014
federal income tax return per Federal IRS Requirements.
If you indicate that you or your spouse were not required to file federal
income taxes, you may be asked to provide documentation from the
IRS to confirm that.
Section A – Monthly Expenses
Complete the following review of monthly expenses and source of payment. You identified yourself as a self-supporting student,
and/or that you provide more than 50% of the support of another person. If your monthly expenses were more than the 2014
income listed on the Free Application for Federal Student Aid (FAFSA) or the income listed above, provide an explanation in the
“Statement” section. Do not leave any field blank; you must provide a response for each item below, both expense and support. If the
item does not apply to you or your spouse (you did not have a specific expense), you must enter “$0” or “n/a”.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Student/Spouse’s Living Expenses
Household Expenses
Support
from 1/1/14 – 12/31/14
List amount per month
(Overall payment)
List amount per month
Housing (rent, mortgage)
Food
Utilities (home phone, electric/gas, cable, etc.)
Auto (car payment, gas, insurance, maintenance)
Childcare
Credit cards
Medical/Dental
Cell Phone
Other personal expenses (clothing, misc)
Total Monthly Expenses/Income/Support (lines 1-9)
Total Yearly Expenses/Income/ Support (line 10 x 12)
$
$
$
$
$
$
$
$
$
$
$
Who provided
the support?
$
$
$
$
$
$
$
$
$
$
$
Section B – Untaxed Income
List below all sources and amounts of money received by you or your spouse from January 1, 2014 through December 31, 2014.
Include any untaxed income, earnings or income not reported on a federal income tax return. Do not leave any field blank; you must
provide a response for each item on this form. If the item does not apply to you or your spouse (you did not receive the form of income),
you must enter“$0” or “n/a”. While these amounts may not be used on the FAFSA, they may demonstrate family income; documentation
may be requested at any time.
How much per month?
Number of months in 2014 assistance received?

Earnings/income from W2, not reported on
federal income tax return
$

Unemployment
$

Supplemental Security Income (SSI)
$

AFDC/TANF Benefits
$

Disability Income
$

Free or Reduced Lunch / WIC

I/We lived with relative or someone else who provided me/us with free room and board in 2014.
Revised 03/20/15
Section B – Untaxed Income (con’t)
Student
$
$
If no items apply to you (or your parents), enter zeros. Documentation will be required and must be attached for us to
Spouse
exclude these dollar amounts from your financial aid calculation.
Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including but not limited to, $
amounts reported on W2 form in boxes 12a-d, codes D, E, F, G, H, and S. (2014 W2 forms, other statements of payment)
$
IRA deductions and payments to self-employed SEP, SIMPLE, Keogh or other qualified plans from IRS Form 1040 (lines
28+32), or 1040A (17)
(2014 federal taxes)
(Provide documentation) $
$
$
$
Child support received for all children. Do not include foster care or adoption payments.
$
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.
(2014 federal taxes)
$
Housing, food, and other living allowances paid to members of the military, clergy, and others (including cash payments and $
cash value of benefits). Do not include the value of on-base military housing or the value of a basic military allowance for
housing.
(Provide documentation)
Veterans' non-education benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and / $
or VA Educational Work-Study allowances.
(Provide documentation)
$
Any other untaxed income or benefit such as worker's compensation, disability, not reported in items 45a-h (above).
Include untaxed portions of health savings accounts from IRS form 1040, line 25. (2014 statement of benefit(s) rec’d)
Do not include: extended foster care benefits, student aid, earned income credit, additional child tax credit, welfare payments,
untaxed social security benefits, supplemental security income, WIA educational benefits, on-base military housing or military
housing allowance, combat pay, benefits from flexible spending arrangements (cafeteria, medical, childcare plans), foreign
income exclusion or credit for federal tax on special fuels.
$
Cash received, or any money paid on your behalf (i.e. bills paid for you), not reported elsewhere on this form. This
includes money that you received from a parent whose financial information is not reported on this form, and that is not part
of a legal child-support agreement. You must include distributions to you as student beneficiary from a 529 plan that is
owned by someone other than you or your parents (such as your grandparents, aunts/uncles).
$
$
$
Tax exempt interest income from IRS Form 1040 (8b) or 1040A (8b).
(2014 federal taxes) $
Untaxed portions of IRA distributions from IRS Form 1040-lines (15a minus 15b) or 1040A-lines (11a minus 11b). Exclude $
rollovers.
(2014 federal taxes)
Statement: If you claim to be a self-supporting student, and if your income was not sufficient to pay rent, foods, and other expenses,
explain how your expenses were met. (You may attach a separate sheet if additional space is needed.) If your income has increased in
2015, please explain how, and list your total anticipated income (taxable and nontaxable) for 2015. Documentation may be requested.
This form will be considered incomplete and returned to you for completion if the explanation is missing or does not provide enough
detail.
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I/We hereby certify that all information reported on this form and any attachments is true, complete, and accurate. I understand that if this
form is incomplete, it will delay review of my financial aid eligibility. False statements or misrepresentation will be cause for denial,
reduction, withdrawal, and/or repayment of financial aid. If you purposely give false or misleading information on this application,
you may be fined up to $20,000, be sentenced to jail, or both. Signatures are required for student and spouse.
Signature of Applicant
Spouse’s Printed Name
Date
Signature
Date
Revised 03/20/15