Miscellaneous Income Questionnaire

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Miscellaneous Income Ques onnaire
2016-2017
2500 Student Activities Bldg.
515 E. Jefferson St.
Ann Arbor, MI 48109-1316
: 734-763-6600
: 734-647-3081
e
: financial.aid@umich.edu
:
TEL
FAX
MAIL
WEB
This informa on is required to process your applica on for fi nancial aid for Fall/Winter 2016-2017. Complete and return this form
to the address above so your aid applica on can be processed. If you are requested to submit this form and you fail to do so, you may
jeopardize your eligibility for fi nancial aid.
_____________________________________ _____________________
____________________________
Student’s Name: Last
First
M.I.
UMID Number (8 digits)
Email Address
If you are:
A Dependent Student (or a Pharmacy or Dental Student Applying for a Health Professions Loan): Provide informa on for yourself
and your parents. Complete both le and right columns.
An Independent Student: Provide informa on only for yourself (and your spouse if you have one). Complete le column only.
Student’s/
Parents’
Report the Following Income Exclusions (List Informa on for Calendar Year 2015):
Spouse’s
Informa on
Informa on
$
Child support you paid because of divorce or separa on or as a result of a legal requirement.
$
Don’t include support for children in your (or your parents’) household, as reported on the FAFSA.
• List full name(s) of child(ren) being supported and amount paid for each child:
Name of Person
Name of Person to Whom
Name of Child for Whom
Amount of Child
Who Paid Child Support
Child Support was Paid
Support was Paid
Support Paid in 2015
$
Taxable earnings from need-based employment programs, such as Federal Work-Study and need-
$
based employment por ons of fellowships and assistantships.
$
Student grant and scholarship aid reported to the IRS in your (or your parents’) adjusted gross
$
income. Includes AmeriCorps benefi ts (awards, living allowances, and interest accrual payments), as
well as grant or scholarship por ons of fellowships and assistantships.
$
Combat pay or special combat pay. Only enter the amount that was taxable and included in your
$
adjusted gross income. Do not enter untaxed combat pay reported on W-2 (Box 12, Code Q).
$
$
Earnings from work under a coopera ve educa on program off ered by a college
Student’s/
Parents’
Report the Following Untaxed Income (List Informa on for Calendar Year 2015):
Spouse’s
Informa on
Informa on
$
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 deduc ons and payments to self-employed SEP, SIMPLE, Keogh and other qualifi ed plans from
$
IRS Form 1040 (line 28 plus line 32) or 1040A (line 17).
$
Child support received for any of your parents’ children. Don’t include foster care or adop on
$
payments.
$
$
Tax exempt interest income from IRS Form 1040 (line 8b) or 1040A (line 8b).
$
Untaxed por ons of IRA distribu ons from IRS Form 1040 – (lines 15a minus 15b) or 1040A (lines
$
11a minus 11b). Exclude rollovers. If nega ve, enter a zero here*.
$
Untaxed por ons of pensions from IRS Form 1040 – (lines 16a minus 16b) or 1040A (lines 12a minus
$
12b). Exclude rollovers. If nega ve, enter a zero here*.
* If “rollover” not listed on 1040 – provide documenta on.
(con nued on next page)
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