Financial Aid
450 North Avenue • Battle Creek, MI 49017-3397
269-965-4123 • FAX 269-966-4089
www.kellogg.edu/nancial-aid
KELLOGG
COMMUNITY COLLEGE
2019-2020
Household Resources
Verication Form
For Expenses and Income for 2017
EXS or EXP
Your 2019-2020 FAFSA was selected for review in a process called verication. The law states that before awarding Federal
Student Aid, you will need to conrm your Household Resources for 2017. Financial Aid Oce may request documentation to
verify your income.
SECTION 1:
Sources of Earned Income: Annual Amount: $
(Wages from employment W-2’s or 1099 forms)
Sources of Unearned Income: Annual Amount: $
(List ALL sources such as DHS, SSI, and FIA Etc.…)
SECTION 2:
Include the MONTHLY expenses for the head of the household. If you were not employed or did not receive any
untaxed income, but reside with individual(s) who support you, please indicate what you paid for the following:
Head of Household Name
Relationship to you Number in Household
Monthly expenses to consider are as follows:
Rent/Mortgage $ Clothing $
Utilities-Electric, Gas,
Water
$
Phone, Internet,
Cable
$
Car Payment, Auto
Gas, Maintenance
$ Car Maintenance $
Insurance Premiums $ Debit/Credit Cards $
Insurance Premiums $ Other Miscellaneous $
Child Support Paid $ Entertainment $
Food $ Medical/Dental $
Personal Expenses $ Child Care $
Total Amount of
Column 1
$
Total Amount of
Column 2
$
Total Monthly Expenses
Column 1 + Column 2
$
# months you resided in
the Household
X
Total Yearly Expenses = $
Divided by # in
Household
÷
Total Support Provided = $
** In the space provided, include
a statement of support for your
family during the year of 2017.
**
SECTION 3:
Incarceration - Please include the dates during the year of 2017 that you were incarcerated:
Beginning date: Release date:
Please provide taxable and non-taxable income for any portion of the year 2017 you were not incarcerated using sections 1 & 2.
Student Signature Student ID # Date
Head of Household (HOH) Signature HOH Social Security Number
Updated 3/19
