*UNTXDC* 1516 *TRACKING REQUIREMENT*
2014 UNTAXED INCOME CERTIFICATION – DEPENDENT (STUDENT/PARENTS)
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/or your parent(s)’ total income from all sources for 2014 appears to be
unusually low, or you indicated that your parent(s) 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 parent(s)’ 2014 federal
income tax return transcript.
 My parent(s) did not file, and are not required to file, a 2014
federal income tax return per Federal IRS Requirements.
If you indicate that you or your parents 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. If your parent(s)’ 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 your parent(s) (they did not have a specific expense), they must enter “$0” or
“n/a”.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Parent(s)’ Living Expenses
Household Expenses
How much 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 parent(s) 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 parents (they did not receive the form
of income), they must enter “$0” or “n/a”. Documentation may be requested.
Assistance Programs:
How much per month?
Number of month’s assistance received in 2014?

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

Parents lived with relative or someone else who provided them with free room and board in 2014.
Revised 03/17/15
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
Parent
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 your parent(s)’ income was not sufficient to pay rent, food, and other expenses, explain how their expenses were met. (You
may attach a separate sheet if additional space is needed.) If their income has increased in 2015, please explain how, and list their 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 parents.
Signature of Applicant
Date
Parent (1) / Stepparent’s Printed Name
Signature
Date
Parent (1) / Stepparent’s Printed Name
Signature
Date
Revised 03/13/15