ICC Financial Assistance Office
1 College Drive
t Peoria, IL 61635-0001
Phone: (309) 694-5
Fax: (309) 694-
email: financialaid@icc.edu
Revised April 16, 2020 KR
Student Name:
ICC Student ID:
In reviewing your financial aid application, ICC needs to verify your means of support. Your PARENT(s) must list their monthly expenses, their monthly
amount of support and the source of support that they received in the 2018 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 PARENT(s) total expenses are greater than their total income, please explain on the back how they
supported the household in 2018. Attach another sheet of paper if needed.
A. Expenses Complete the information for January 1, 2018 to December 31, 2018
Monthly Expenses Monthly 2018 Expenses
(How the expense was paid or who paid the expense.)
Rent or Mortgage
Subsidized Housing
Yes (amount received $______________)
No (who paid rent/mortgage: ____________________)
Utilities Gas/Electric/Water
Energy Assistance
Yes (amount received $______________)
No (who paid utilities___________________________)
Food Stamps
Yes (amount received $______________)
No (who paid for food:__________________________)
Telephone/Cell Phone
Transportation: Payments, Insurance, Gas,
Oil Changes, repairs, etc.
Medical Expenses
Personal Expenses clothing, personal, etc.
Total Expenses
B. Income Complete the information for January 1, 2018 to December 31, 2018
Type of Income
Monthly 2018 Income
Who Received the Income
Wages Earned by student and spouse
Pension Benefits
Social Security
Unemployment Benefits
Severance Pay
Cash from Relatives/Friends
Child Support
Workmen’s Compensation
Other (Please explain on the back)
Total income
The student and one parent listed on the FAFSA must sign and date this worksheet. Each person signing this form certifies that all the information reported
on it is complete and correct. WARNING: If you purposely give false or misleading information on this form; you may be fined, be sentenced to jail, or both.
Student Signature
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.
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