Verification Form Susquehanna University (Page 3 of 3) in pdf

: ___________________________________________

TUDENT NAME

Student

2015 Untaxed Income

Parent

Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings),

including, but not limited to, amounts reported on the W-2 Form in Boxes 12a through 12d,

codes D, E, F, G, H, and S.

IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and other qualified plans

from IRS Form 1040–total of lines 28 + 32 or 1040A–line 17.

Child support received for all children. Do not include foster care or adoption payments

received.

Tax exempt interest income from IRS Form 1040–line 8b or 1040A–line 8b.

Untaxed portions of IRA distributions from IRS Form 1040–lines (15a minus 15b) or 1040A-

lines (11a minus 11b). Exclude rollovers. If negative, enter a zero.

Untaxed portions of pensions from IRS Form 1040–lines (16a minus 16b) or 1040A- lines (12a

minus 12b). Exclude rollovers. If negative, enter zero.

Housing, food, and other living allowances paid to members of the military, clergy, and others

(including cash payments and cash value of benefits).

Veterans’ non-education benefits such as Disability, Death Pension, or Dependency &

Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.

Other untaxed income not reported, such as worker's compensation, disability, etc. Do not

include student aid, earned income credit, child tax credit, welfare payments, untaxed Social

Security benefits, Workforce Investment Act educational benefits, combat pay (if you are not a

tax filer), 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 this form.

Total Student

Total Parent

IGN THIS

ORKSHEET

We certify that all the information reported on this worksheet is complete and correct.

Warning: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or

both.

Student Signature

Date

Parent Signature

Date

Please return to:

Student Financial Services

Susquehanna University

514 University Ave.

Selinsgrove, PA 17870

FAX: 570/372-2722

Office use only.

V1 V4

Page 3 of 3

Verification Form Susquehanna University Page 3

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