Miscellaneous Income Questionnaire Page 2
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1
2(FUNTAX)
Student’s/
Parents’
Report the Following Untaxed Income (List Informa on for Calendar Year 2015):
Spouse’s
Informa on
Informa on
$
Housing, food, and other living allowances paid to members of the military, clergy, and others
$
(including cash payments and cash value of benefi ts). Don’t include the value of on-base military
housing or the value of a basic military allowance for housing.
$
Veteran’s noneduca on benefi ts, such as Disability, Death Pension, or Dependency & Indemnity
$
Compensa on (DIC) and/or VA Educa onal Work-Study allowances.
Other untaxed income not reported above, such as workers’ compensa on, disability, etc. Don’t
include student aid, earned income credit, addi onal child tax credit, welfare payments, untaxed
Social Security benefi ts, Supplemental Security Income, Workforce Investment Act educa onal
benefi ts, on-base military housing or a military housing allowance, combat pay (if your parents are
not tax fi lers), benefi ts from fl exible spending arrangements (e.g., cafeteria plans), foreign income
exclusion or credit for federal tax on special fuels.
List source(s) of untaxed income and amount(s):
$___________
_________________________________________________________________________________
$___________
$___________
_________________________________________________________________________________
$___________
$___________
_________________________________________________________________________________
$___________
$
Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form.
$
This includes money you received from a parent whose fi nancial informa on is not reported on this
form and that is not part of a legal child support agreement.
Do you receive?
Government Benefi ts Received By Your Household
(circle YES or NO)
Supplemental Social Security (SSI) (NOT survivor or Social Security re rement benefi ts)
Name and age of recipients:
______________________________________________________________________ _________
YES
NO
______________________________________________________________________ _________
______________________________________________________________________ _________
Food Stamps (SNAP – Supplemental Nutri on Assistance Program)
YES
NO
Temporary Assistance for Needy Families (TANF)
YES
NO
Special Supplemental Nutri on Program for Women, Infants, and Children (WIC)
YES
NO
Name of recipient:
Free-or-Reduced Lunch in 2015 or 2016
YES
NO
This form MUST have all required signatures before you submit it.
I (we) cer fy that the informa on provided on this form is complete and correct to the best of my (our) ability. I/we also agree to contact
the U-M Offi ce of Financial Aid if the informa on provided here changes.
____________________________________
_____________
_____________________________________
_____________
Date
Date
Student’s Signature
Parent’s Signature
o:/trkenclo/untax1617.indd 011216
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