UNIVERSITY OF NEVADA, LAS VEGAS
STUDENT FINANCIAL SERVICES
OFFICIAL USE ONLY
4505 MARYLAND PARKWAY BOX 452016
LAS VEGAS, NV 89154-2016
D
PHONE: (702) 895-3424
FAX: (702) 895-1353
Email: sfsssc@ccmail.nevada.edu
http://www.unlv.edu/SFS
2001-2002 PARENT UNTAXED INCOME (D)
STUDENT NAME
SOCIAL SECURITY NUMBER
Student Financial Services has completed an initial review of your Free Application for Federal Student Aid
(FAFSA). Additional information is needed. Please complete and return this form to Student Financial
Services. Your parent(s) must complete all of the answers on the front and back of this form, even if the
answer is zero. Incomplete forms will be returned and will cause a delay in processing your application. If your
parent is remarried, your stepparent's information is required.
ALL PROCESSING OF YOUR AID HAS STOPPED UNTIL YOU ACT UPON THIS REQUEST.
SECTION A.
Please provide total yearly amounts you (and your spouse, if married) received from January 1,
2000 through December 31, 2000. You may wish to refer to your 2000 federal tax return, tax
schedules, W2s, 1099s and other year end benefit statements to help you complete the following:
1. My parent(s) received Earned Income Credit on their 2000 Federal tax return.
See Form 1040-line 60a; Form 1040A-line 38a; Form 1040EZ-line 8a; or
Telefile-line L.
$______________
2. My parent(s) received additional child tax credit. See Form 1040-line 62; or
1040A-line 39.
$______________
3. My parent(s) received welfare benefits, including Temporary Assistance for
Needy Families (TANF). Do NOT include food stamps.
$______________
4. My parent(s) received UNTAXED Social Security Benefits. See IRS Form
1040-lines (20a minus 20b); Form 1040A-lines (14a minus 14b); OR your
Social Security Administration year-end benefits statement, Form 1099.
$______________
SECTION B.
Please provide total yearly amounts you (and your spouse, if married) received from January 1,
2000 through December 31, 2000 in the form of other untaxed income and benefits NOT reported
on your 2000 federal tax return.
1. My parent(s) made contributions to tax-deferred pension and savings plans;
either paid directly or withheld from earnings. Include untaxed portions of
401K and 403b plans; exclude flexible spending arrangements, e.g., cafeteria
plans. See W-2s, BOX 13 for total amount of deferred compensation.
$_______________
SECTION B. (Continued)
2. My parent(s) reported IRA deductions and payments to self-employed SEP,
SIMPLE, and Keogh and other qualified plans. See IRS Form 1040-lines
(23 plus 29); or Form 1040A-line 16.
$_______________
3. My parent(s) received child support payments for children living in their
home. Do NOT include foster care or adoption assistance payments under
Title IV-A or IV-E of the Social Security Act.
$_______________
4. My parent(s) received tax-exempt interest income. See IRS Form 1040 or
1040A-line 8b.
$_______________
5. My parent(s) received foreign income, which was excluded from federal
income taxes. See IRS Form 2555-line 43 or Form 2555EZ-line 18.
$_______________
6. My parent(s) received untaxed portions of pensions. Do NOT include
rollovers. See IRS Form 1040-lines(15a minus 15b) + (16a minus 16b)
or 1040A-lines (11a minus 11b) + (12a minus 12b).
$_______________
7. My parent(s) received a Federal tax credit on special fuels. See IRS Form
4136-line 9 (non-farmers only).
$_______________
8. My parent(s) received housing, food and other living allowances as
members of the military, clergy, and others (including cash payments and
cash value of benefits). Include basic allowance for housing. Exclude rent
subsidies for low-income housing.
$_______________
9. My parent(s) received veteran’s non-education benefits such as Death
Pension, Dependency and Indemnity Compensation (DIC), etc. Do NOT
include education benefits, e.g. GI Bill, Dependents Education Assistance
Program, VA Vocational Rehabilitation Program, VEAP benefits, etc.
$_______________
10. My parent(s) received other types of untaxed income and benefits not
reported elsewhere in Section A or B, such as worker’s compensation,
untaxed portions of railroad retirement benefits, Black Lung Benefits,
Refugee Assistance, etc. Do NOT include student aid, WIA educational
benefits (formerly JTPA), or benefits from flexible spending arrangements.
$_______________
11. My parent(s) received cash or money paid on my/our behalf, not reported
elsewhere on this form. Do NOT include non-monetary gifts/support
received from friends/relatives.
$_______________
We certify the information given on both sides of this form is true and complete.
________________________________________________________________________________________
STUDENT SIGNATURE
DATE
________________________________________________________________________________________
PARENT SIGNATURE
DATE
2002 Parent Untaxed Income.02/05/01