2019-2020 Income and Expenses Verification Form (Student)
STUDENT NAME: ____________________________ PUID: ____________________________
The income reported on your Free Application for Federal Student Aid (FAFSA) does not give a clear picture of
how your family met their expenses for the 2017 calendar year. Please complete this form so the Office of
Financial Aid can evaluate your eligibility for financial aid. Explain how you were able to cover expenses such as
housing, food and utilities.
SECTION 1: Income and Expenses
On your 2019-2020 FAFSA you reported minimal or no income, assets or savings for calendar
year 2017 Please list below all of your income and expenses in 2017
Complete the entire form. If the answer is zero enter (0) or (N/A).
2017 Income
Monthly
A
mount
Income from Work (gross amount)
Business Income
Social Security Benefits
Unemployment Benefits
Disability Benefits
Worker’s Compensation
Alimony
Child Support Received
Rental Assistance (TANF)
Food Stamps (SNAP)
Cash Assistance from
Cash Received
Money Paid On Your Behalf
Other Sources
Total Income
2017 Expenses
Monthly
Amount
Mortgage/Rent
Homeowners/Rental Insurance
Utilities (electric, gas, water)
Phone (home and cell)
Car Payment
Car Insurance
Transportation (fuel, bus, train)
Food/Groceries
Medical/Dental Care
Medical/Dental Insurance
Medications/Prescriptions
Clothing
Other Expenses
Total Expenses
SECTION 2: Explanation of Situation
Please explain your situation. Include as much detail as possible about how your family covered the expenses
listed above for calendar year 2017 An explanation is also required if few or no expenses were listed in Section 1.
If you used savings, a line of credit, etc. to meet your expenses, attach three consecutive monthly statements
from those accounts. Use the back of this form to write your explanation.
SECTION 3: Certification Signatures
Your signature(s) certify that all the information reported on this form is complete and correct.
Student Signature: _______________________________________ Date: _____________________
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1401 S. U.S. Hwy. 421 * Westville, IN 46391
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Toll-Free: 1-855-608-4600
website: pnw.edu
