2019–2020 Income and Expenses
The income reported on your 2019–2020 Free Application for
Federal Student Aid (FAFSA) appears to be insufficient to meet basic living expenses.
The law says that before disbursing financial aid, we may ask you to confirm the information reported on the FAFSA. This purpose of this worksheet is to
determine how the basic needs of your household were met during the prior year. Please respond to each item. Indicate “0” (zero) or “N/A” if an item
does not apply to you. Your responses must be accurate and verifiable. Incomplete forms will not be processed. If you have any questions, contact
Financial Aid Services as soon as possible so that your financial aid will not be delayed.
A. Student’s Information
______________________________________________________________
Student’s Last Name Student’s First Name Studen
t’s M.I.
______________________________________________________________
Student’s Permanent Street Address (include apt. no.)
______________________________________________________________
City State Zip Code
______________________________________________________________
Student’s Home Phone Number (include area code)
XXX-XX-
Last 4 digits of Social Security Number
__________________________________
Student’s Date of Birth
__________________________________
Student’s Email Address
__________________________________
Student’s Cell Phone Number
B. Household Expenses State the actual (or average) dollar amount paid per month in 2017 next to each
expense item.
MONTHLY HOUSEHOLD EXPENSES 2017
AMOUNT PAID PER MONTH
1. Home Mortgage/Rental.............................................
$__________________________
2. Real Estate Taxes......................................................
$__________________________
3. Utilities (Phone, gas, heat, electric, water, etc.).......
$__________________________
4. Food and Household Supplies...................................
$__________________________
5. Automobile Payments................................................
$__________________________
6. Auto Insurance, Gas, Repairs and/or transportation..
$__________________________
7. Educational Expenses (excluding financial aid).......
$__________________________
8. Life and Health Insurance..........................................
$__________________________
9. Medical Expenses Not Covered By Insurance..........
$__________________________
10. Child Care/Day Care..................................................
$__________________________
11. Clothing.....................................................................
$__________________________
12. Credit Cards...............................................................
$__________________________
13. Miscellaneous............................................................
$__________________________
TOTAL MONTHLY EXPENSES
$
Please complete this form electronically, and then print, sign and return to Financial Aid Services
1
Per FAFSA, if you are an independent student, answer below as it
applies to your household in 2017.
Be sure to include spouse information
if you are married.
An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed
forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk
of becoming homeless. A dependent student is someone who does not meet any of the criteria for an independent student. For questions regarding your
dependency status, please contact the financial aid office at finaid@moravian.edu or 610-861-1330.
Per FAFSA, if you are a dependent student, answer below as it applies
to your parent(s) household in 2017. Be sure to report information for
your parent as reported on the FAFSA.
Report information below in sections B. Household Expenses, C. Household Resources, and D. Other Information as it applies to your household in 2017.
Before responding b
elow, consider the following definitions:
2
Employer’s Name or Form of Income
2017 Annual Amount Earned Document Attached?
Susie’s Auto Body or Social Security Disability (example)
$2,050.00 (example) Yes(example)
1._________
YES/NO Are/were any of your expenses on the previous page paid by another person? If YES, please explain below:
_____________________________________________________________________________________________________________
________
____________________________________________________________________________________________________
_________
E. Certification and Signatures
Each person signing below certifies that all of the information
r
eported is complete and correct.
_
_
_______________________________________________
Student
S
ignature
(signature required)
_
________________________________________________
Parent
Signature (if dependent student) OR
Spouse Signature
(if independent and married)
_
________________________________
Date
______
___________________________
Date
WARNING: If you purposely give false or misleading
information on this wor
ksheet, you may be fined, sent
to prison, or both.
Return to: Office of Financial Aid Services, Colonial Hall Moravian College, 1200 Main Street, Bethlehem, PA 18018-6650 FAX: 610-861-1346
was not employed and had no income
earned from work
was employed and had earnings*
received some other type of income/
resource*
was not employed and had no income
earned from work
was employed and had earnings*
received some other type of income/
resource*
were not employed and had no
income earned from work
were employed and had earnings*
received some other type of income/
resource*
*
Please list all income and other resources (by name/type and dollar amount earned) that were used to meet the monthly expenses listed on the
previous page. Be sure to list every employer or resource, even if an employer or resource did not issue an IRS W-2 form or other form. For each
so
urce for which you have documentation, please provide the document(s) confirming the income/resource and dollar amount. (Examples of
acceptable documents: W-2 forms, social security statements (SSI, SSDI), unemployment statements, child support documentation, bank
statements, etc.)
In 2017, one or both of the
dependent student's parent(s):
In 2017, the independent student's
spouse (only if married):
boyfriend, girlfriend, etc.)? If YES, please explain below:
2.
YES/NO Are/were you residing with or supported by another person (e.g., your parent, relative, friend,
C. Monthly Resource
If
the student is an independent student and is not married, below apply to the student only. If the student is an independent student and is
married, the instructions and certifications below apply to the student and the student's spouse. If the student is a dependent student, below apply to
each parent included in the household. Complete this section if the independent student (and spouse if married) or dependent student's parent(s) will
not file and are not required to file a 2017 income tax return with the IRS.
Check the boxes that apply:
I
n 2017, the independent student
(regardless of marital status):
D.Other Information
If the student was required to provide parent information on the FAFSA, answer each question below as it applies to the student’s parent(s) whose
information is on the FAFSA. If the student was not required to provide parent information on the FAFSA, answer each question below as it
applies to the student (and the student’s spouse, only if married).
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