2018-2019 Student Inco
me Clarification Form
Student Name ___________________________ Student ID or SSN ______________ Phone _______________
Please return this completed form and all other required materials to:
Ottumwa Campus: IHCC, Attn. Financial Aid, 525 Grandview Avenue, Ottumwa, Iowa 52501 Fax: 641-683-5741, Email: OneStop@indianhills.edu
Centerville Campus: IHCC, 721 North First Street, Centerville, IA 52544 Fax: 641-856-3158
To check the status of your documents, go to WebAdvisor and click the Financial Checklist, under the Financial Aid heading.
Enter your 2016 income & expenses for each line item, if ZERO, write 0 or NA. Blank lines will be considered
STUDENT/SPOUSE INCOME - CALENDAR YEAR 2016
Wages, Salaries, & Tips (See W-2 for yearly amount & divide by 12)
Social Security Benefits/Supplemental Security Income
Unemployment Compensation/Worker’s Compensation
Savings Used to Pay Expenses/Cash Given by Friends or Relatives
*If someone else provided or paid for your expenses in 2016 list the cost of each expense they paid under
“Paid by family/other.”
STUDENT/SPOUSE EXPENSES – CALENDAR YEAR 2016
Expenses Lines 13-17 are Required
Groceries-Must be greater than>0 or check a box
Housing-rent, mortgage, property tax, insurance,
Maint. Must be >0, check a box, or complete #15
If you had no housing expenses, check who
provided your housing & calculate your share of
rent paid on your behalf.
payment by # of occupants
Utilities-cable, phone, natural gas, electric,
garbage, etc. Must be >0 or check a box
Personal-clothing, hygiene products, etc. Must be >0
Transportation-gas, car payment, insurance, bus pass, auto maint., etc.
Total Monthly Expenses or Bills
Did you use a Financial Aid Refund to help with your expenses in 2016?
Does “Total Monthly Expenses or Bills,” listed above, exceed your “Total Monthly Income?” If so,
please explain how you/your family were able to meet your basic needs during 2016. For example, did
you utilize a financial aid refund, Job Corps, or did someone else pay your expenses, etc.
Certification and Signature: I certify that all of the information reported is complete and correct. WARNING: If you purposely give false or misleading information,
you may be fined, sent to prison, or both. I acknowledge an incomplete form may delay my financial aid disbursement. A hand written signature, not typed, is
Student’s Signature (Required)