2020-2021 Student Income Clarification Form
Please return this completed form to Indian Hills Community College along with any other requested materials:
Fax: 641.683.5741│ Mail: IHCC Financial Aid Office, 525 Grandview Ave, Ottumwa, IA 52501
or bring to One Stop/Bennett Student Services Building
You can check your financial aid document status, print required forms, and view your financial aid award information (once available) on WebAdvisor.
Student’s Name Student’s ID # Phone
Enter your 2018 income & expenses for each line item, if ZERO, write 0 or NA. Blank lines will be considered
STUDENT/SPOUSE INCOME - CALENDAR YEAR 2018
1 Wages, Salaries, & Tips (See W-2 for yearly amount & divide by 12)
2 Social Security Benefits/Supplemental Security Income
3 Unemployment Compensation/Worker’s Compensation
5 Food Assistance/SNAP
6 Housing Allowance
7 Child Support/Alimony
8 Day Care Assistance
9 Savings Used to Pay Expenses/Cash Given by Friends or Relatives
10 Veteran Benefits
11 Other: Explain
If someone else provided or paid for your expenses in 2018 list the cost of each expense they paid under
STUDENT/SPOUSE EXPENSES – CALENDAR YEAR 2018
Expenses Lines 13-17 are Required
Groceries-Must be greater than>0 or check a box
Housing-rent, mortgage, property tax, insurance,
Maint. Must be >0, check a box, or complete #15
If you had no housing expenses, check who
provided your housing & calculate your share of
rent paid on your behalf.
payment by # of occupants
Utilities-cable, phone, natural gas, electric,
garbage, etc. Must be >0 or check a box
Personal-clothing, hygiene products, etc. Must be >0
Transportation-gas, car payment, insurance, bus pass, auto maint., etc.
Total Monthly Expenses or Bills
24 Did you use a Financial Aid Refund to help with your expenses in 2018? No Yes
25 Does “Total Monthly Expenses or Bills,” listed above, exceed your “Total Monthly Income?” If so,
please explain how you/your family were able to meet your basic needs during 2018. For example,
did you utilize a financial aid refund, Job Corps, or did someone else pay your expenses, etc.
Certifications and Signatures Each person signing below certifies that all of the information reported is complete and correct. WARNING: If you
purposely give false or misleading information, you may be fined, sent to prison, or both.
Electronic signatures will not be accepted.
Student’s Signature (Required)