Fillable 2020-2021 Low/No Income Verification Dependent (DLIV) (Wayne Community College)

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2020-2021 Low/No Income Verification Dependent (DLIV) (Wayne Community College)

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The 2020-2021 Low/No Income Verification Dependent (DLIV) (Wayne Community College) form is 2 pages long and contains:

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  • 7 check-boxes
  • 90 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wayne Community College

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CONTINUED ON REVERSE
2020-2021
Low/No Income Verification – Dependent (DLIV)
STUDENT NAME:
____________________________________________________________ WCC ID: ______________________________
ADDRESS:
___________________________________________ ________________________________________ ____________ _______________
STREET OR PO BOX CITY STATE ZIP
The income reported on your 2020-2021 FAFSA seems too low to meet basic living expenses. While this may be due to the valid
exclusion of certain types of income from the FAFSA, federal law states that we have the right to confirm the information that was
submitted before offering and/or disbursing federal student aid. This worksheet may be requested in addition to other verification forms
required by the U.S. Department of Education. PLEASE NOTE – Your eligibility for financial aid cannot be determined until the
verification process is complete.
INSTRUCTIONS: You, and a parent whose information was reported on the FAFSA, should complete this worksheet using blue or
black ink, attach any required documentation, sign, and submit the completed package to the WCC Financial Aid Office. IMPORTANT:
If your parent was married/remarried on the day you signed and submitted the FAFSA, you are required to include information
for each parent and/or stepparent.
The Financial Aid Office will compare the information reported on the FAFSA for you and your parent(s) with the information provided
on this worksheet and any other required documentation. If there are any discrepancies between the information reported on your
FAFSA and the documents submitted to our office, your signature on this form authorizes our office to make the appropriate
corrections to your FAFSA.
A. INCOME SOURCES
Provide information about YEARLY income received for the period of January 1, 2018 through December 31, 2018. You
must enter a response for EACH question below. If an item does not apply to you, please enter -0- or N/A.
STUDENT
PARENT(S)
DOCUMENTATION
Earnings from work
$ _______________
$ _______________
All 2018 Form W-2’s, 1099’s or other
statements of income earned
Pension or Retirement Funds
$ _______________
$ _______________
2018 IRS Form 1099-R
Unemployment Compensation
$ _______________
$ _______________
2018 IRS Form 1099-G
Social Security (disability or SSI)
$ _______________
$ _______________
2018 SSA-1099 (Social Security Office)
Worker’s Compensation
$ _______________
$ _______________
Final payment stub from 2018
Veteran’s Non-Educational Benefits
$ _______________
$ _______________
VA Award Letter
Child Support (received for all
applicable dependents)
$ _______________
$ _______________
Proof of Child Support received
January – December 2018
Alimony or Spousal Support
$ _______________
$ _______________
Court Order
Other (gifts, financial aid refunds,
lottery or gambling winnings, etc.)
$ _______________
$ _______________
To be determined
Total Income from all sources
$ _______________
$ _______________
B. GOVERNMENT ASSISTANCE
Review the federal assistance programs below and enter a check mark for all that were received by any member of your
parents’ household during 2018 OR 2019. *Answering these questions will NOT reduce your eligibility for student aid or these programs.
Housing Assistance (Section 8,
HUD, etc.)
Food & Nutrition Services (food
stamps, SNAP, EBT, etc.)
Supplemental Security Income
(SSI)
Work First/TANF/AFDC
WIC
Medicaid
I/We did not receive any government assistance in 2018
C. INCARCERATION
Yes
No
If yes, the period of incarceration was: ______________ to _____________. Attach proof of incarceration (may vary by location)
RETURN THIS COMPLETED FORM WITH REQUIRED DOCUMENTATION TO:
Wayne Community College - Financial Aid Office - PO Box 8002 - Goldsboro, NC 27533-8002
FAX: 919-736-9425
Wayne Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate degrees. Contact the
Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation of Wayne Community College.
The Commission on Colleges may be contacted only if there is evidence that Wayne Community College is significantly non-compliant with a requirement or standard.
Accreditation standards are located at http://www.sacscoc.org/principles.asp. Inquiries about Wayne Community College, such as admission requirements, financial aid,
educational programs, etc. should be addressed directly to Wayne Community College and not the Commission’s office.
D. MONTHLY EXPENSES
Looking back at 2018, enter the AVERAGE MONTHLY cost for typical living expenses listed below for
your parents’
household. You must provide a response for EACH question below. If an item does not apply to you, please enter -0- or N/A.
Monthly Expense Monthly Cost
Who Paid?
(enter amount paid by each source)
If paid by “other”,
provide name/relationship
Parent Other
# months
paid
Housing* (rent, mortgage, etc.)
$____________
________
________
______
____________________________
Food* (groceries, meals out)
$____________
________
________
______
____________________________
Utilities* (gas, water, electric)
$____________
________
________
______
____________________________
Internet/Cable TV*
$____________
________
________
______
____________________________
SUBTOTAL
$____________
* If these expenses were paid by “other”, who is listed as the owner or tenant on mortgage or lease documents?
_________________________________________________________
Phone
$____________
________
________
_______
____________________________
Childcare/Dependent Care
$____________
________
________
_______
____________________________
Transportation (fuel, car payment,
maintenance, or public transit)
$____________
________
________
_______
____________________________
Clothing
$____________
________
________
_______
____________________________
Personal Care Items (toiletries)
$____________
________
________
______
____________________________
Other: ________________
$____________
________ ________
______
____________________________
SUBTOTAL
$____________
FAO USE -
IN-KIND: $ __________
UNTAXED INC.: ____________
E. OTHER
Use the space below to provide any other information that will explain how your parent(s) met basic living expenses in
2018.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
F. CERTIFICATION AND SIGNATURES
By signing below, I certify that all information reported on this form and any documentation provided is true and complete.
____________________________________________________
STUDENT SIGNATURE (REQUIRED)
_________________________
DATE
____________________________________________________
PARENT SIGNATURE (REQUIRED)
_________________________
DATE
WARNING: If you purposely provide false or misleading information to obtain financial aid, you may be fined, sentenced to jail, or both.
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2020-2021 LowNo Income Verification Dependent (DLIV) (Wayne Community College)

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Completed 26 July 2020

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