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 Independent Means of Support
Student’s Name:____________________________________________ ICC Student ____________________________
In reviewing your financial aid application, you and/or your spouse reported an income that appears exceptionally low according
to the U. S. Department of Education. On this form, you must list your monthly expenses, your monthly amount of support and the
source of support that you 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 total expenses are greater than your total
income, please explain on the back how you and/or your spouse supported your 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 expense
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 student and spouse
$
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
$
Each person signing this form certifies that all the information
reported on it is complete and correct. If married, spouse’s
signature is optional.
Student Signature
Date
Spouse Signature (optional)
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.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome