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
Student Name:
ICC Student ID:
In reviewing your financial aid application, you and/or your spouse reported an income that appears exceptionally low according to the U. S. Department of
Education. On this form, you must list your monthly expenses, your monthly amount of support and the source of support that you 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 total expenses are greater
than your total income, please explain on the back how you and/or your spouse supported your 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)
Total income
Each person signing this form certifies that all the information reported on it is complete and correct. If married, spouse’s signature is optional.
FEDERAL 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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