Financial Aid Office ● 197 Franklin St. • Auburn, NY  13021

   315-255-1743 • Fax 315-252-2185


2014-2015 OTHER UNTAXED INCOME AND BENEFIT WORKSHEET


 

 

_____________________________________________________________________________________________

Student’s Printed Name                                                                                                                  Cayuga ID #

 

The Federal Government has selected your application for verification of untaxed income and benefits you may have received in 2013. 

 

Instructions

 

Ø  This form is used for both students (and spouses) and for parents of dependent students. An independent student does not need to complete the parent section.  A dependent student should complete both the student and the parent section.

Ø  DO NOT LEAVE BLANKS.  PLACE A ZERO.  Blanks will be assumed the student or parent did not read the question and this form will be returned to you, delaying your application.

Ø  Include annual amounts for 2013.  If you only know the monthly amount, take that amount and multiply by 12.

Ø  Attach a copy of all W-2 forms.

 

 

2013 Parent and Student (and Spouse) Untaxed Income

Parents

Student and/or

Spouse

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 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)

Be sure to attach a copy of your W-2 Forms

 

$

 

$

IRA deductions and payments to self-employed SEP, SIMPLE, KEOUGH and other qualified plans from IRS Form 1040-line 28 + line 32 or 1040A-line 17.

$

$

Child Support received for any of your children.  Don’t include foster care or adoption payments.  List the children (full name) below who you are receiving child support payments for:

1.       _____________________________________________________________

 

2.       _____________________________________________________________

 

3.       _____________________________________________________________

 

4.       _____________________________________________________________

 

5.        

Page 2 :  2013 UNTAXED INCOME AND BENEFITS

$

 

 

 

 

 

 

 

PARENT

$

 

 

 

 

 

 

 

Student

and/or

Spouse

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.

List the member(s) of the household who is receiving this benefit below:

1.       ______________________________________________________

 

_____________________________________________________________

 

$

 

S

Veterans noneducation benefits, such as Disability, Death Pension or Dependency & Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.

List the member(s) of the household who is receiving this benefit below:

1.       ____________________________________________________

 

___________________________________________________________

 

$

 

$

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

List the member(s) of the household who is receiving this benefit below:

1.       ____________________________________________________

 

___________________________________________________________

 

 

$

 

 

$

Untaxed portions of health savings accounts from IRS Form 1040- Line 25.

 

 

2.       Money received or paid on your behalf (such as., bills, insurance, rent), not reported elsewhere on this form. Dependent students do not report support received from parents

XXXX

$

2.        

 

 

 

 

Certification

I(we) certify under penalty that all of the information on this form is complete and accurate.

____________________________________________________________        _________________

      Student's Signature                                                                                 Date

____________________________________________________________        _________________

      Parent's Signature                                                                                    Date