ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5311
Fax: (309) 694-5160
email: financialaid@icc.edu
Rev. March 14, 2019
2019-2020 Dependent Means of Support
Student’s Name: ________________________________________ ICC Student ID #_____________________________
In reviewing your financial aid application, your PARENT(s) reported an income that appears exceptionally low according to the
U.S. Department of Education. On this form, your PARENT(s) must list their monthly expenses, their monthly amount of support
and the source of support that they received in the 2017 calendar year. While it may be difficult to determine some of the figures, it is
necessary to provide us with the most accurate information possible. Complete all items - if something does not apply, enter “0” or
N/A. If all items are not completed the form will be returned to you. If your PARENT(s) total expenses are greater than their
total income, please explain on the back how they supported the household in 2017. Attach another sheet of paper if needed.
A. Expenses Complete the information for January 1, 2017 to December 31, 2017
Monthly Expenses
Monthly expenses
for 2017
Explanation of how the expense was paid or who paid the expenses
Rent or Mortgage
$
Subsidized Housing Yes No If yes, amount $ ____________
If No, who paid the rent or mortgage?
Utilities Gas/Electric/Water
$
Energy Assistance Yes No If yes, amount $ ____________
If No, who paid the utilities?
Food
$
Food Stamps Yes No If yes, amount $ ____________
If No, who paid for the food?
Telephone/Cell Phone
$
Transportation: payments, gas,
insurance, oil changes, repairs, etc.
$
Medical Expenses
$
Personal Expenses: clothing, etc.
$
Total Expenses
$
B. Income - Complete the information for January 1, 2017 to December 31, 2017
Type of Income
Monthly income
for 2017
Who received the income
Wages earned by parent(s)
$
Pension benefits
$
Social Security
$
Unemployment benefits
$
Severance pay
$
Cash from relatives/friends
$
TANF
$
Child support
$
Workers’ Compensation
$
Other (Please explain on the back)
$
Total Income
$
The student and one parent must sign and date this worksheet.
Each person signing this form certifies that all the information
reported on it is complete and correct.
Student Signature
Date
Parent of Dependent Student Signature
Date
It is the policy of this College that no person, on the basis of race, color, religion, gender, national origin, age, disability,
sexual orientation, or veteran’s status, shall be discriminated against in employment, in educational programs and
activities, or in admission. Inquiries and complaints may be addressed to the Compliance Officer, Diversity Department.
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