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Block Style Letter

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2016-2017 Household Resources Worksheet
Student Name _________________________________________

TCTC ID _______________________

Please provide the following information as annual amounts only, not monthly.
 Use actual figures where possible.
 If an item does not apply to you, enter “0”. Each blank must have a response.
 WARNING: If you purposely give false or misleading information, you may be fined, be sentenced to jail or both.
Student
(& Spouse if married) Parent(s)
(if
dependent)

Payments to tax-deferred pension and savings plans as reported on the W2
_____________ Form in Boxes 12a through 12d, codes D,E,F,G,H or S.
____________
Child support received for any children. This includes money you received from a non-custodial parent that is not part of a legal child support agreement. Do not include foster care payments, adoption payments, or any amount that was court_____________ ordered but not actually paid.
____________
Housing, food, and other living allowances paid to members of the military, clergy and others. Include cash payments and/or cash value of benefits received. Do
_____________ not include value of on-base military housing or basic military allowance for housing. ____________
Veteran’s non-education benefits, List total amount of veterans non-education benefits. Include Disability, Death Pension, Dependency and Indemnity Compensation
_____________ (DIC), and/or VA Work-Study allowances.
Any other untaxed income and benefits: List the amount of other untaxed income. Include: workers’ compensation, disability, Black Lung Benefits, amounts from IRS Form 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...

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