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
incomplete.
Line #
STUDENT/SPOUSE INCOME - CALENDAR YEAR 2016
Monthly Amount
1
Wages, Salaries, & Tips (See W-2 for yearly amount & divide by 12)
$
2
Social Security Benefits/Supplemental Security Income
$
3
Unemployment Compensation/Worker’s Compensation
$
4
TANF/ADC/AFDC/FIP
$
5
Food Assistance/SNAP
$
6
Housing Allowance
$
7
Child Support/Alimony
$
8
Day Care Assistance
$
9
Savings Used to Pay Expenses/Cash Given by Friends or Relatives
$
10
Veteran Benefits
$
11
Other: Explain
$
12
Total Monthly Income
$
*If someone else provided or paid for your expenses in 2016 list the cost of each expense they paid under
“Paid by family/other.”
Line #
STUDENT/SPOUSE EXPENSES CALENDAR YEAR 2016
Expenses Lines 13-17 are Required
Check All That Apply
You
*Family/other
13
Groceries-Must be greater than>0 or check a box
Food assist./SNAP
IHCC meal plan
$
$
14
Housing-rent, mortgage, property tax, insurance,
Maint. Must be >0, check a box, or complete #15
Own home
Lived in dorm
Section 8
$
$
15
If you had no housing expenses, check who
provided your housing & calculate your share of
rent paid on your behalf.
Divide rent/housing
payment by # of occupants
Parent
Relative
Friend/Other:
$
$
16
Utilities-cable, phone, natural gas, electric,
garbage, etc. Must be >0 or check a box
Utilities incl. in rent
Home energy asst.
$
$
17
Personal-clothing, hygiene products, etc. Must be >0
$
$
18
Medical/Health Expenses
Medical card
$
$
19
Transportation-gas, car payment, insurance, bus pass, auto maint., etc.
$
$
20
Day Care for Children
$
$
21
Child Support Paid
$
$
22
Other: Explain
$
$
23
Total Monthly Expenses or Bills
$
$
24
Did you use a Financial Aid Refund to help with your expenses in 2016?
No
Yes
25
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
required.
Student’s Signature (Required)
Date
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