Name Relationship to student Amount of annual income and support

Transcription

1 Purpose of Form Generally, the is requested when an independent student reports zero income or very little income on the Free Application for Federal Student Aid (FAFSA) and/or CSS/PROFILE. It may also be requested when a student reports receiving support from parents or others. This form is used to confirm all sources and amounts of income and support received during the 2017 calendar year, and to document the student s expenses during the same time period. General Instructions Section 1: Annual Income, Support and Benefits for Calendar Year 2017 In this section, report the amount of income and support received in If you are married, you must also report income and support for your spouse, which helps to provide a complete picture of household income for Be sure to report all sources, domestic and foreign. Section 2: Annual cash assistance from family and friends (exclude spouse and parents) If you received cash assistance from family and friends, include this in Section 2. This table allows you to report annual amounts received from each source. In the example below, the student received a total of $5700 in support from family. EXAMPLE Name Relationship to student Amount of annual income and support George Glass grandparent $ 1800 Robin Hall sibling $ 3900 Section 3: Annual s In this section, report either the actual cost for each expense. The actual cost of an expense is the amount you paid (or another party paid on your behalf) for the expense. Cash value is the fair market value that a third party would pay to receive a benefit that you received free of charge. For instance, if you lived in your parent s home free of charge, you would report the fair market value, which is the amount that a third party would pay to live in the space. As an independent student, you are required to report all forms of support that you received in EXAMPLE What are your annual transportation costs? other (Please list relationship to Car payment $ 2400 $ 0 $ 2400 $ 0 $ 0 12/14/18 p. 1

2 General Instructions (continued) If your expenses are not covered by your earned income, your, or by, list the cost in the column other. Please define other on the line in the column heading. EXAMPLE What are your annual food/grocery, personal and, if applicable, childcare expenses? student income Childcare $ 4800 $ 2400 $ 0 $ 0 $ 2400 other Non-custodial parent Note that the amount you report as the Total cost of each expense (in the first column with a dollar sign) must equal the combined sum of the amounts listed in the four columns to the right of the total. Student Financial Services may request third-party documentation to confirm the values you report on your. Should you submit a form with incorrect information, you must also submit third-party documentation to confirm the correct values. Adjustments to a aid award as a result of submitting documentation to correct an are neither guaranteed nor immediate. Forms received without the appropriate signature(s) or with missing information or missing pages are considered incomplete and must be resubmitted. This will delay the evaluation of your aid eligibility and the awarding of your aid. 12/14/18 p. 2

3 Student s University ID: - or SIS ID: Student s Full Name: (LEGAL NAME - PRINT) first middle last SECTION 1: ANNUAL INCOME, SUPPORT AND BENEFITS FOR CALENDAR YEAR 2017 Were you employed in 2017? Yes No SOURCE OF ANNUAL INCOME AND SUPPORT FOR STUDENT (AND SPOUSE if married) in 2017 (enter 0 or N/A, if appropriate) Annual income earned from work in 2017 If self-employed or a business owner, withdrawals from a business used in 2017 to meet household or personal expenses. Do not include amounts already reported above as wages. Annual income from social security and/or disability in 2017 Alimony/Spousal support received in 2017 (Exclude if already reported on 2017 tax return) Annual income from child support in 2017 Annual cash or loan assistance from parents in 2017 Annual cash or loan assistance from family and friends other than parents in 2017 (Please complete Section 2 below if you receive this type of support) Annual income from retirement/pension plans in 2017 STUDENT (please leave no blanks) SPOUSE (please leave no blanks) Annual in 2017 Annual on-base military housing or the value of a basic military allowance for housing (as reported on final leave and earnings statement of 2017) Annual housing, food and other living allowances paid in 2017 to members of the military, clergy and others. Do not include the value of military housing or the value of a basic military allowance for housing listed above. Other annual cash received or money paid on your behalf in 2017 not reported above List source(s): Other income in 2017 not reported above List source(s): TOTAL ANNUAL INCOME AND SUPPORT 12/14/18 p. 3

4 Student s University ID: - or SIS ID: Did any family member in the household receive these : (if yes, please check the relevant box) FEDERAL BENEFITS SNAP (Supplemental Nutrition Assistance Program) WIC (Women, Infants and Children supplemental program) TANF (Temporary Assistance for Needy Families) Medicaid or SSI (Supplemental Security Income) Free or reduced price lunch Other benefit (such as subsidized housing) List source(s): SECTION 2: ANNUAL CASH ASSISTANCE FROM FAMILY AND FRIENDS (exclude spouse and parents) Name (enter N/A, if appropriate) Relationship to student (enter N/A, if appropriate) SECTION 3: ANNUAL EXPENSES FOR CALENDAR YEAR 2017 HOUSING Your living situation in 2017: (please check the relevant box at right) or cash value of housing Own a home Dates: Rent Dates: Live free of charge with somebody, including parents (Provide cash value at the bottom of this table see instructions) Explain relationship: student and Dates: Amount of annual income and support (please leave no blanks) $ $ Will you live with them during the academic year? Yes No Is your name listed on your rental agreement or mortgage? Yes No other 12/14/18 p. 4

5 Student s University ID: - or SIS ID: What are your annual food/grocery, personal and, if applicable, childcare expenses? Food/groceries Personal expenses Childcare other What are your annual utility costs? Water/Sewage Phone Cell Phone other Cable/Internet Electricity Natural Gas/Oil 12/14/18 p. 5

6 Student s University ID: - or SIS ID: What are your annual transportation costs? other Car payment Maintenance Fuel Fares What are your annual education expenses? other Tuition and Fees Books Other What are your annual insurance costs? Health/Dental/ Vision Insurance other Automobile Insurance Homeowners/ Rental Insurance Life Insurance 12/14/18 p. 6

7 Student s University ID: - or SIS ID: Do your annual expenses exceed your annual income and support? If YES, please include a signed statement with any relevant details, including how you are able to meet your expenses. If you are using a loan or credit card(s) to meet your expenses, you must also submit the loan promissory note or credit card statement(s) to verify this. Yes Include statement, attach additional pages if necessary No If you are required to (or would like to) include a written explanation of your circumstances, please do so here. Attach additional pages if necessary. CERTIFICATION STATEMENT: I certify that all the information reported to qualify for federal aid is complete and correct to my knowledge. If additional documentation is required, I will submit those documents in a timely manner. I understand that if I purposely give false or misleading information, I may be fined, sentenced to jail, or both and my aid may be terminated. STUDENT SIGNATURE Date 12/14/18 p. 7