CONTINUED ON REVERSE
2019-2020
Low/No Income Verification Dependent (DLIV)
STUDENT NAME: _____________________________________________ WCC ID #: _______________________
The income reported on your 2019-2020 FAFSA seems to be too low to meet basic living expenses. While this may be due to the valid
exclusion of certain types of income from the FAFSA, federal law states that we have the right to confirm the information that was
reported before awarding and/or disbursing federal student aid. This worksheet may be requested in addition to other verification forms
required by the U.S. Department of Education. PLEASE NOTE Your eligibility for financial aid cannot be determined until the
verification process has been completed.
INSTRUCTIONS: You, and a parent whose information was reported on the FAFSA, must complete this worksheet in blue or
black ink, attach any required documentation, sign, and submit the completed package to the WCC Financial Aid Office.
IMPORTANT: If your parent was married/remarried on the day you first signed and submitted the FAFSA, you are required to
include information for each parent and/or stepparent.
The Financial Aid Office will compare the information reported on the FAFSA for you and your parent(s) with the information reported
on this worksheet and any other required documentation. If there are any discrepancies between the information reported on your
FAFSA and the documents submitted to our office, your signature on this form authorizes our office to make the appropriate
corrections to your FAFSA.
INCOME SOURCES
Provide information about YEARLY income received from January 1, 2017 through December 31, 2017. You must enter a
response for EACH question below. If an item does not apply to you, please enter -0- or N/A.
STUDENT
PARENT(S)
DOCUMENTATION
Earnings from work
$ _______________
$ _______________
All 2017 Form W-2’s, 1099’s or other
statements of income earned
Pension or Retirement Funds
$ _______________
$ _______________
2017 IRS Form 1099-R
Unemployment Compensation
$ _______________
$ _______________
2017 IRS Form 1099-G
Social Security
$ _______________
$ _______________
2017 SSA-1099 (Social Security Office)
Worker’s Compensation
$ _______________
$ _______________
Final payment stub from 2017
Veteran’s Non-Educational Benefits
$ _______________
$ _______________
VA Award Letter
Child Support (received for all
applicable dependents)
$ _______________
$ _______________
Proof of Child Support received
January December 2017
Alimony or Spousal Support
$ _______________
$ _______________
Court Order
Other (gifts, financial aid refunds,
lottery or gambling winnings, etc.)
$ _______________
$ _______________
To be determined
Total Income from all sources
$ _______________
$ _______________
GOVERNMENT ASSISTANCE
Review the federal assistance programs below and enter a check mark for all that were received by any member of your
parents’ household. *Answering these questions will NOT reduce your eligibility for student aid or these programs.
Housing Assistance (Section 8,
HUD, etc.)
Food & Nutrition Services (food
stamps, SNAP, EBT, etc.)
Supplemental Security Income
(SSI)
Work First/TANF/AFDC
WIC
Medicaid
I/We did not receive any government assistance in 2017
INCARCERATION
Yes
No
If yes, the period of incarceration was: ______________ to _____________. Attach proof of incarceration (may vary by location)
RETURN THIS COMPLETED FORM WITH REQUIRED DOCUMENTATION TO:
Wayne Community College - Financial Aid Office - PO Box 8002 - Goldsboro, NC 27533-8002
FAX: 919-736-9425
Wayne Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate degrees. Contact the
Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation of Wayne Community College.
The Commission on Colleges may be contacted only if there is evidence that Wayne Community College is significantly non-compliant with a requirement or standard.
Accreditation standards are located at http://www.sacscoc.org/principles.asp. Inquiries about Wayne Community College, such as admission requirements, financial aid,
educational programs, etc. should be addressed directly to Wayne Community College and not the Commission’s office.
MONTHLY EXPENSES
Provide the AVERAGE MONTHLY cost for the typical living expenses listed below for your parents’ household. You must enter
a response for EACH question below. If an item does not apply to you, please enter -0- or N/A.
Monthly Expense Monthly Cost
Who Paid?
(enter or X)
If paid by “other”,
provide name/relationship
Parent
Other
Housing (rent, mortgage, etc.)
$____________
________
________
, _____________________________
Food (groceries, meals out)
$____________
________
________
, _____________________________
Utilities (gas, water, electric)
$____________
________
________
, _____________________________
Phone (cell or landline)
$____________
________
________
, _____________________________
Internet/Cable TV
$____________
________
________
, _____________________________
Childcare/Dependent Care
$____________
________
________
, _____________________________
Transportation (fuel, car payment,
maintenance, or public transit)
$____________
________
________
, _____________________________
Clothing
$____________
________
________
, _____________________________
Personal Care Items (toiletries)
$____________
________
________
, _____________________________
Other: ________________
$____________
________
________
, _____________________________
TOTAL EXPENSES
$____________
TOTAL X 12 months = $ _____________________________
OTHER
Use the space below to provide any other information that will explain how your parent(s) met basic living expenses in
2017.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
CERTIFICATION AND SIGNATURES
By signing below, I certify that all information reported on this form and any documentation provided is true and complete.
_________________________
DATE
____________________________________________________
STUDENT SIGNATURE (REQUIRED)
____________________________________________________
PARENT SIGNATURE (REQUIRED)
_________________________
DATE
WARNING: If you purposely provide false or misleading information to obtain financial aid, you may be fined, sentenced to jail, or both.
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