| OU-HCOM Change of Income Form 2013-2014 | |||||||||
| Name : | |||||||||
| Social Security Number: | |||||||||
| Please indicate the reason(s) for your change of income: | |||||||||
| My last date of employment was: | |||||||||
| My spouse's (if applicable) last date of employment was: | |||||||||
| IMPORTANT--You MUST attach the following documentation: | |||||||||
|
• A copy of your final pay stub showing IRS income information • For spouse, attach a letter from employer indicating last date of employment |
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| 2013 ESTIMATED INCOME INFORMATION | |||||||||
| Enter the total gross yearly income that you (and your spouse) expect to receive from January 1, 2013 until December 31, 2013 from the sources indicated below. If a question does not apply to you, write N/A in the answer space. | |||||||||
| Student wages, salaries, tips | Estimated 2013 untaxed income | ||||||||
| Spouse wages, salaries, tips | Social Security benefits received for all family members | ||||||||
| Interest income | |||||||||
| Dividend income | Worker's compensation | ||||||||
| Alimony | Disability benefits | ||||||||
| Business income (or loss) | Public assistance (ADC, ADFC) | ||||||||
| Capital or other gains (or loss) | Living & housing stipends for military, and others | ||||||||
| IRA distributions | |||||||||
| Pensions and annuities | Child support received for all family members | ||||||||
| Rental income (or loss) | |||||||||
| Farm income (or loss) | Veterans non-educational benefits | ||||||||
| Unemployment | IRA/Keogh Plans | ||||||||
| Any other taxable income | Credit for special fuels | ||||||||
| Specify source: | Earned Income Credit | ||||||||
| Total 2013 Gross Taxable Income | Contributions to tax deferred pensions/savings plan | ||||||||
| including 401(k) and 403(b) | |||||||||
| Any other untaxed income and benefits Specify source: | |||||||||
| Alimony/child support to be paid in 2013 | |||||||||
| Total 2013 Untaxed Income | |||||||||
| CERTIFICATION STATEMENT | |||||||||
| All of the information on this form is true and complete to the best of my knowledge. Is asked, I agree to provide further proof of the information I have given on this form. I understand that if I purposely give false or misleading information, I may be subjected to a fine, prison sentence, or both. | |||||||||
| Signature | Date | ||||||||