Income Certification Form Prattmwp

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PrattMWP Financial Aid Office
Phone: (315) 797-0000 ext 2222
310 Genesee Street
Fax: (315) 797-9349
Utica, NY 13502
Email: finaid@mwpai.edu
UNTAXED INCOME CERTIFICATION FORM
2016-2017
Student Name: _______________________________________Student ID: _______________
On your FAFSA Application your parent(s) reported a low taxable family income for 2015. Please indicate below how
your parent(s) met living expenses in 2015. Examples of expenses include: housing, utilities, food, transportation, etc…
Please give dollar amounts for all incoming funds.
/yr.
Child Support Received
Supplemental Nutrition Assistance Program (SNAP-food stamps)
/yr.
Worker’s Compensation
/yr.
Veteran’s Benefits (excludes veterans’ education benefits)
/yr.
Housing, food and other living allowances paid to members of the military, clergy and
others. (Don’t’ include the value of on-base military housing or the value of a basic
/yr.
military allowance for housing)
In Kind/Cash Support (value of free rent, food, utilities, etc…)
/yr.
Cash Assistance
/yr.
Untaxed portions of IRA distributions (IRS Form 1040-lines (15a minus 15b) or
/yr.
1040A-lines (11a minus 11b). Do not include ROLLOVERS. (If negative, enter zero)
Untaxed portions of pensions (IRS Form 1040-lines (16a minus 16b) or 1040A-lines (12a
/yr.
minus 12b). Do not include ROLLOVERS. (If negative, enter zero)
/yr.
Tax Exempt Interest (IRS Form 1040-line 8b or Form 1040A-line 8b)
IRA deductions and payments (IRS Form 1040-line 28+ line 32 or 1040A-line 17.
/yr.
Payments to tax-deferred pensions and savings plans (W-2 forms boxes 12a
/yr.
through12d, codes D, E, F, G, H and S only)
/yr.
Social Security Benefits
Supplemental Security Income
/yr.
Other (please explain):
Parent Signature: __________________________________________________Date: ___________________

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