2016-17 Untaxed Income Worksheet
You may type your information directly onto this form, print to sign, then submit it to the Office of Student Financial
Aid. To avoid processing delays, do not submit this form until you have gathered all required documents/forms
requested from you.
Section 1. Student Information
Last name
First name
UA Student ID #:
Middle Initial
Last 4 digits of SSN:
Section 2. Household Information
Please complete this table in its entirety. Enter "0" where appropriate. Do not leave any blanks.
Information should be reported for the calendar year 2015. Do not leave any blanks!
Student/Spouse
Parent #1 and Parent #2
Payments to tax-deferred pensions and savings plans (paid directly or withheld
from earnings) including, but not limited to, amounts reported on W2 form(s)
in boxes 12a through 12d, codes D, E, F, G, H, and S.
Child support received for all children. Don't include foster care or adoption
payments.
Housing, food, and other living allowances received because you are a member
of the clergy (and other professions) 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 non-education benefits, such as Disability, Death Pension, or
Dependency and Indemnity Compensation (DIC), and/or VA Educational WorkStudy Allowances.
Other non-taxed income not reported elsewhere, such as workers'
compensation, disability, etc. Don't include student aid, earned income credit,
additional child tax credit, untaxed Social Security/Social Security Income
benefits, etc.
Money received, or paid on your behalf (e.g. bills, etc.) not reported
elsewhere on this form.
Section 3. W2s. W2 statements must be submitted with this form for dependent students, independent students, spouses of
independent students who are married, and parents of dependent students. Submit Schedule C/C-EZ if income was from selfemployment.
Section 4. Certification. Each person signing this worksheet certifies that all of the information reported on it is complete and
accurate. Warning: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
Student signature:
Date:
Parent signature:
Date:
Electronic signatures will not be accepted.
Please print this form to sign before
submitting.
Section 5. Submission.
Do not submit this form until you have gathered all other required documents/forms to avoid delays in processing. When you have
all required documents/forms as instructed by your To Do list in My Akron, you may mail, fax, or scan/email your documents (both
sides) to us at the information listed below, or you may turn them into ZipAssist in the Simmons Hall Lobby.
Form25
The University of Akron w Student Financial Aid w Akron, OH 44325-6211 w Fax: 330-972-7139 w Email: [email protected]