V6 - Household Resources Verification Group (Page 3 of 4) in pdf

Student Name:____________________

Student ID NO:_________________

If you reported any untaxed income for questions 45 or 94 on your 2016-2017 FAFSA,

please verify this below by letting us know the amount. Do not leave Blank, Check N/A or Zero

Student FAFSA Question 45

Parent(s) FAFSA Question 94

$__________ Payments to tax-deferred pension and retirement savings plans $________

(paid directly or withheld from earnings), including, but not

limited to amounts reported on the W-2 forms in Boxes 12a

through 12d, codes D,E, F, G, H and S. Don’t include amounts

reported in code DD (employer contributions toward employee

health benefits).

$__________ IRA deductions and payments to self-employed SEP, SIMPLE, $________

Keough and other qualified plans from IRS Form 1040-line

28 + 32 or 1040A-line 17.

$__________ Child support received for any of your parents’ children. Don’t $________

include foster care or adoption payments

$__________ 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.

$__________ Untaxed portions of pensions from IRS Form 1040-lines (16a

$________

minus 16b) or 1040A-lines (12a minus 12b). Exclude rollovers.

$__________ Housing, food and other living allowances paid to members of $ ________

the military, clergy and others (including cash payments and

cash value of benefits). Don’t include the value of on-base

military housing or the value of a basic military allowance for

housing.

$__________ Veterans noneducation benefits, such as Disability, Death

$ ________

Pension or Dependency & Indemnity Compensation (DIC)

And/or VA Educational Work-Study allowances.

$__________ Other untaxed income not reported above such as workers’

$ ________

compensation, disability, etc. Also include the untaxed

portions of health savings accounts from IRS Form 1040-

line 25. Don’t include extended foster care benefits, student

aid, earned income credit, additional child tax credit, welfare

payments, untaxed Social Security benefits, Supplemental

Security Income, Workforce Investment Act educational

benefits, on-base military housing or a military housing

allowance, combat pay, benefits from flexible spending

arrangements (e.g., cafeteria plans), foreign income exclusion

or credit for federal tax on special fuels.

V6 - Household Resources Verification Group Page 3

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