Independent Student Review of Other Income During 2021

Student Name*

First

Last
Student ID*

Your Free Application for Federal Student Aid (FAFSA) has been flagged by the U.S. Department of Education due to conflicting financial information reported for 2021. The U.S. Department of Education requires that Tidewater Community College collect information about any untaxed income and/or additional financial information that you or your spouse received to support your household during 2021. Federal law stipulates that schools maintain the right to review this information before awarding federal aid, in order to comply with federal regulations. Any errors on your FAFSA that are discovered after review of this form will be corrected electronically by Tidewater Community College with the U.S. Department of Education and further documentation may be required.

Please Note:

Please list annual amounts of untaxed income below. If you or your spouse paid or received the same dollar amount every month in 2021, multiply that amount by the number of months in 2021 you paid or received it. If you or your spouse did not pay or receive the same amount each month in 2021, add together the amounts you paid or received each month to report the annual amount.
A. Payments to tax-deferred pension and retirement savings

List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings plans (e.g., 401(k) or 403(b) plans), including, but not limited to, amounts reported on W-2 forms in Boxes 12a through 12d with codes D, E, F, G, H, and S.

List the payments for Section A

Name of Person who Made the Payment	Total Amount Paid in 2021

B. IRA Deductions & payments to self-employed SEP, SIMPLE, Keough, and other qualified plans.

List the total amounts from IRS 1040 Schedule 1– line 16 and line 20.

List the payments for Section B

Name of Person who Made the Payment	Total Amount Paid in 2021

C. Untaxed Portions of IRA distributions and pensions

List amount from IRS 1040 – lines 4a+4c minus lines 4b+4c. Exclude Rollovers.

List the payments for Section C

Name of Person who Made the Payment	Total Amount Paid in 2021

D. Tax exempt interest income

List amounts from IRS 1040 – line 2a.

List the payments for Section D

Name of Person who Made the Payment	Total Amount Paid in 2021

E. Child Support Received

List the actual amount of child support received in 2021 for the children in your household. Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid.

List the support received for Section E

Name of Adult who Received Child Support	Name of Child for Whom Support was Received	Total Amount Paid in 2021

F. Housing, food, and other living allowances paid to members of the military, clergy, and others

Include cash payments and/or the cash value of benefits received. Do not include the value of on-base military housing or basic military allowance for housing.

List the benefits received for Section F

Name of Recipient	Type of Benefit Received	Amount of Benefit Received in 2021

G. Veterans non-education benefits

List the total amount of Veterans non-education benefits received in 2021. Include Disability, Death Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowance. Do not include federal Veterans educational benefits such as: Montgomery GI Bill, Dependents Education Assistance Program, VEAP Benefits, orPost-9/11 GI Bill.

List the benefits received for Section G

Name of Recipient	Type of Veterans Non-Education Benefit Received	Amount of Benefit Received in 2021

H. Other Untaxed Income

List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include untaxed income such as workers’ compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040, Schedule 1- Line 13, Railroad Retirement Benefits, etc. (Do not include the following items: Any items reported or excluded in A – D above, 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.)

List the untaxed income for Section H

Name of Recipient	Type of Other Untaxed Income	Amount of Other Untaxed Income Received in 2021

I. Money received or paid on your behalf (e.g., bills, not reported elsewhere on this form)

List any money received or paid on the student and/or household member’s behalf (e.g., payment of bills) and not reported elsewhere on this form. Enter the total amount of cash support received in 2021. Include support from a parent whose information was not reported on the student’s FAFSA, but do not include support from a parent whose information was reported. For example, if someone is paying rent, utility bills, etc., for a household member or gives cash, gift cards, etc., include the amount of that person's contributions unless the person is the student’s parent whose information is reported on the student’s FAFSA. Amounts paid on the household member’s behalf also include any distributions from a 529 plan owned by someone other than the student or the student’s parents, such as grandparents, aunts, and uncles of the student.

List the funds for Section I

Purpose (e.g., cash, rent, books, etc.)	Amount Received in 2021	Source

J. Education Credits (American Opportunity Tax Credit and Lifetime Learning Tax Credit).

Amount from IRS Form 1040 – Schedule 3, line 3.

List the Education Credits for Section J

Name of Recipient	Amount Received in 2021	Source

K. Earnings from work under a cooperative education program offered by a college.

List the earnings for Section J

Name of Recipient	Amount Received in 2021	Source

L. Child Support Paid

List the actual amount of child support paid in 2021 because of divorce or separation or as a result of a legal requirement. Don’t include support for children in your household.

List the child support for Section L

Name of Person Who Paid Child Support	Name of Person to Whom Child Support was Paid	Name and Age of Child for Whom Child Support was Paid	Total Amount of Child Support Paid in 2021

M. Taxable earnings from need-based employment programs

Such as Federal Work-Study and need-based employment portions of fellowships and assistantships.

List the Taxable Earnings for Section M

Name of Recipient	Type of Taxable Earnings	Amount of Taxable Earnings Received in 2021

N.Taxable college grant and scholarship aid reported to the IRS in your adjusted gross income.

Includes AmeriCorps benefits(awards, living allowances and interest accrual payments), as well as grant and scholarship portions of fellowships and assistantships.

List the Grants or Scholarships for Section N

Name of Recipient	Type of taxable grant and/or scholarship	Amount of Taxable grant and/or Scholarship in 2021

O. Combat pay or special combat pay

Only enter the amount that was taxable and included in your adjusted gross income. Don’t include untaxed combat pay.

List the combat pay for Section O

Name of Recipient	Amount of Taxable Combat Pay Received in 2021

P. Certification and Signature

By signing this form, I certify that all of the information, income, and support received has been reported and is true and correct. I understand that purposely giving false or misleading information could result in a fine, imprisonment or both as it relates to my reporting information to the U.S. Department of Education.
Student's Signature*
Spouse's Signature

Independent Student Review of Other Income During 2021

Step 1 of 5

A. Payments to tax-deferred pension and retirement savings

B. IRA Deductions & payments to self-employed SEP, SIMPLE, Keough, and other qualified plans.

C. Untaxed Portions of IRA distributions and pensions

D. Tax exempt interest income

E. Child Support Received

F. Housing, food, and other living allowances paid to members of the military, clergy, and others

G. Veterans non-education benefits

H. Other Untaxed Income

I. Money received or paid on your behalf (e.g., bills, not reported elsewhere on this form)

J. Education Credits (American Opportunity Tax Credit and Lifetime Learning Tax Credit).

K. Earnings from work under a cooperative education program offered by a college.

L. Child Support Paid

M. Taxable earnings from need-based employment programs

N.Taxable college grant and scholarship aid reported to the IRS in your adjusted gross income.

O. Combat pay or special combat pay

P. Certification and Signature