2016-2017
Dependent Supplemental Untaxed Income Form
Please complete and submit this form to:
Office of Student Financial Assistance
104 Fairchild Hall | 1601 Vattier Street
Manhattan, KS 66506-1104
Office 785-532-6420 | Toll free 877-817-2287 | Fax 785-532-7628
Website ksu.edu/sfa | Email finaid@ksu.edu
Student’s Name (Last, First, MI)
Wildcat Identification Number
Student’s K-State Email Address
Student’s Phone Number
The untaxed income information on your original FAFSA was not provided or is incomplete. Due to federal regulations, your
untaxed income information is required to complete the federal verification process. Additional information is needed to clarify
the total amounts received in 2015.
Untaxed Income
Student
Annual Amount
Parent(s)/StepParent
Annual Amount
Payments to tax-deferred pension and retirement 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. Do not include amounts reported in code DD (employer contributions
toward employee health benefits).
IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and
other qualified plans from IRS Form 1040 - line 28 + line 32 or 1040A - line
17.
Child support received for any of your children. Do not include foster care
or adoption payments.
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.
Veterans noneducation benefits, such as Disability, Death Pension, or
Dependency and Indemnity Compensation (DIC), and/or VA Educational
Work-Study allowances.
Other untaxed income not reported above, such as workers’ compensation,
disability, etc. Also include the untaxed portions of health savings accounts
from IRS Form 1040 - line 25. 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,
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.
Money received or paid on your behalf (e.g. bills), not reported elsewhere on
the form. This includes money that you received from a parent whose
financial information is not reported on the FAFSA and that is not part of a
legal child support agreement. Note: Also include distributions to you (the
student beneficiary) from a 529 plan that is owned by someone other than
you or your parents (such as your grandparents, aunts, uncles, and noncustodial parents).
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Certification Statement
By signing this verification form, I certify that all of the information reported is complete and accurate.
Signature of Student (required)
Digital signatures are not accepted.
Date
Signature of Parent on FAFSA (required)
Digital signatures are not accepted.
Date