2020-2021 Income Verification Worksheet
Student’s Name: _ _
ID/SSN:
Parent’s
Name: _
_
_
Please fill in the U.S. dollar amount of your family’s average monthly living expenses and sources of income. If an expense occurs other than monthly,
please convert it to a monthly average. Do not report any business or rental property expenses or income used to meet those expenses on this page. If
an item does not apply, indicate this by writing “0 (zero).” If income does not meet expenses, please explain on the back side of this form.
Average Monthly
Amount Student
Average Monthly
Amount
Parent(s)
House Payment (Mortgage) or Rent
Home Property Tax (If not included in House Payment)
Utilities (Gas, Electric, Phone, Water, etc.)
Insurance (Home, Car, Health, Life, etc.)
Monthly Food and Household Supplies Expenses
Average Monthly
Amount Student
Average Monthly
Amount
Parent(s)
Gifts from Family Members
I (we) declare that the information reported on this form and any attachments hereto is true, complete, and accurate to the
best of my (our) knowledge.
Student
Signature:
_
_
Date:
Parent
Signature:
_
Date:
As per HB 1922 (Subtitle A, Title 5, Government Code, Chapter 559), it is the policy of the state that an individual is entitled, on request, to receive,
review and/or correct any information about the individual, which has been submitted to WCJC, with few exceptions. The information WCJC collects will
be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules.
