The Completed Form Can Be Returned To

2018-2019 Other Untaxed Income Worksheet

Please complete this form for yourself and for the parent whose information was provided on the FAFSA. If you (the student) were not required to provide parental information on the FAFSA, answer each of the following questions as it applies to the student (and your spouse, if married). If any item does not apply, enter “N/A” or “0”.

To determine the correct annual amount for each item: If you paid or received the same dollar amount each month in 2016, multiply that amount by the number of months in 2016 you paid or received it. If you did not pay or receive the same amount each month, add together the amounts that you paid or received each month.

The completed form can be returned to:

Mail: Kettering University

Financial Aid Office

1700 University Avenue

Flint, MI 48504-6214

Fax: 810-762-9807

Federal law restricts the way in which documents are submitted to the Financial Aid Office.For your safety and security, Personally Identifiable Information (PII) should never be sent via email. Documents attached to an email are no longer accepted to protect the privacy of student information.The most secure methods to submit documents to the Financial Aid Office are by fax, postal mail or in person.

1. Student Information

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Last NameFirst Name M.I.Student ID#

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Address (include apt. #)Date of Birth

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CityStateZip CodePhone Number (include area code)

1. Child Support Received

1. Other Untaxed Income

• List the amount of other untaxed income. Include untaxed income such as workers’ compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS from 1040 Line 25, Railroad Retirement Benefits, etc.
• DO NOT INCLUDE student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits, combat pay, benefits from flexible spending arrangements (e.g. cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels.

1. Sign This Worksheet

Each person signing this form certifies that all the information reported on it is complete and correct. The student and at least one parent (if applicable) must sign and date this form.

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Student’s SignatureDate

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Parent’s Signature (if applicable)Date