2019-2020 Student Income Clarification Form
Please return this completed form to Indian Hills Community College along with any other requested materials:
Fax: 641.683.5741│ Mail: IHCC Financial Aid Office, 525 Grandview Ave, Ottumwa, IA 52501
or bring to One Stop/Bennett Student Services Building
You can check your financial aid document status, print required forms, and view your financial aid award information (once available) on WebAdvisor.
Student’s Name
Student’s ID #
Phone
Enter your 2017 income & expenses for each line item, if ZERO, write 0 or NA. Blank lines will be considered
incomplete.
Line #
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 2017 list the cost of each expense they paid under
“Paid by family/other.”
Line #
Monthly Amount Paid by:
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 2017?
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 2017. For example, did
you utilize a financial aid refund, Job Corps, or did someone else pay your expenses, etc.
Certifications and Signatures Each person signing below certifies 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.
A hand written signature, not typed, is required
Student’s Signature (Required)
Date
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