Fillable 2021-2022 Household Support Worksheet (V6) (Eastern Wyoming College)

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2021-2022 Household Support Worksheet (V6) (Eastern Wyoming College)

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10/2020
Financial Aid Office
3200 West C Street
Torrington, WY 82240
p: 307.532.8224
f: 307.532.8222
financialaid@ewc.wy.edu
2021-2022
Household Support Worksheet (V6)
The 2019 income reported on your 2021-2022 FAFSA is below average for annual expense estimates. While we understand that
individuals and families can meet basic needs and additional expenses in a variety of manners, the Financial Aid Office is required to
follow-up and verify income amounts, in-kind support, as well as benefits that may not have been included on the original FAFSA as
these items can impact eligibility for certain types of aid. You must also complete the Standard Verification (V1) Worksheet.
Please note: ALL fields are required. If a section is left blank, or if all areas are marked “N/A” without a sufficient
explanation, the form will be returned to you and marked as incomplete.
________________________________________________________ ___________________ _____________________________
Last Name First Name EWC Student ID Number Phone number
*ensure your voicemail is set-up and is not full
Dependent students (included parent(s)’ info on FAFSA): complete the worksheet based on your parent(s) household and information.
Independent students: complete the worksheet based on your and your spouse’s (if applicable) household and information.
HOUSING and UTILITIES,
(gas, power, water, internet, cable, etc.)
& FOOD/GROCERY
MISCELLANEOUS
(credit cards, cell phone,
clothing, child care, other
expenses not listed)
TRANSPORTATION
(car payment, gas, insurance,
public transit, rides from
family/friends, etc.)
2019 Expenses
Please indicate your family’s
living situation in 2019. Select
all that apply.
Rent
Own/Mortgage
Live with relative/other
How were 2019 housing and
utility, and food/grocery needs
met? Select all that apply.
Self
Relative/Friend
Benefits
How were 2019 miscellaneous
expenses met? Select all that
apply.
Self
Relative/Friend
Benefits
Please indicate your family’s
mode of transportation for 2019
below. Select all that apply.
Personal vehicle
Public transit
Rides from relative/friends
Benefits
Other
If you had a vehicle that you (or
your parent if dependent) drove
to/from school or work, please
indicate the status of ownership:
Vehicle paid for by self
Vehicle paid for by other
N/A (other mode of
transportation)
If you had a vehicle that you (or
your parent if dependent) drove
to/from school or work, please
indicate who usually paid for
gas and/or vehicle maintenance
(oil changes, etc.):
Paid for by self
Paid for by other
N/A (other mode of
transportation)
Please also indicate who paid
for auto insurance:
Paid for by self
Paid for by other
N/A (other mode of
transportation)
CHILD SUPPORT PAID. Did your family pay child support for any children not listed in your
household on the Standard Verification (V1) Worksheet? Please list the TOTAL ANNUAL amount
paid for each child by Self in 2019. Attach a separate sheet or provide a statement if needed/preferred.
If you did not pay child support in 2019, please list “N/A” on the first line:
Name: ________________________________________ Age: __________ $____________________
Name: ________________________________________ Age: __________ $____________________
Name: ________________________________________ Age: __________ $____________________
INCOME BENEFITS
2019 Income & Benefits
Did your family receive any income in 2019?
Select all that apply.
Student:
Income earned from work
Income earned “under the table”
Did not earn income
Parent(s) or Spouse (if applicable):
Income earned from work
Income earned “under the table”
Did not earn income
For all earned income, you MUST
submit
student, and parent/spouse (as applicable)
2019 W-2 forms. If you do not have 2019 W2s,
you must provide a statement that includes your
name(s), the type/name of your business, your gross
income, and why you were unable to provide W-2s
(e.g., self-employment). Sign and date.
Did your family receive any of these benefits at
any time in 2019 or 2020? Select all that apply.
N/A (Not applicable)
Medicaid or Supplemental Security
Income (SSI)
SNAP (Food Stamps)
Free or Reduced Price School Lunch
TANF
WIC
AFDC
Low-Income Housing
LIEAP
Other: ____________________________
__________________________________
Other: ____________________________
__________________________________
Dependent students: complete the worksheet based on your parent(s) household. Independent students: complete the worksheet
based on your and your spouse’s (if applicable) household. Please note: ALL fields are required. If a section is left blank, or if all
areas are marked as “N/A” without a sufficient explanation, the form will be returned to you and marked as incomplete.
2019 OTHER Income and Benefits
CHILD SUPPORT RECEIVED. Did your family receive child support for any children who ARE listed in your household on the
Standard Verification (V1) Worksheet? Please list the TOTAL ANNUAL amount received for each child in 2019. Attach a separate
sheet or provide a statement if needed/preferred. If your family did NOT receive child support in 2019, list “N/A” on the first line:
Name: ___________________________________________________________________ Age: __________ $____________________
Name: ___________________________________________________________________ Age: __________ $____________________
Name: ___________________________________________________________________ Age: __________ $____________________
HOUSING, FOOD, AND OTHER LIVING ALLOWANCES
(paid to members of the military, clergy, and others).
Please list the total cash value received in 2019. If you received
free room and board in 2019 for a job that was not awarded as
student financial aid, its value must be included in this figure. DO
NOT include rent subsidies for low-income housing, the value of
on-base military housing or the value of a basic military
allowance for housing. If not applicable, please list “N/A”:
$ ____________________
VETERANS NON-EDUCATION BENEFITS
Please list the total amount of veterans non-education benefits
received in 2019. Include Disability, Death Pension, Dependency
and Indemnity Compensation (DIC), and/or VA Educational
Work-Study allowances. DO NOT include federal veteran’s
educational benefits such as: Montgomery GI Bill, Dependents
Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill.
If not applicable, please list “N/A”:
$ ____________________
OTHER UNTAXED INCOME
Please list the amount of other untaxed income not reported and not listed elsewhere on this form.
Include items such as disability benefits, workers’ compensation, untaxed portions of health savings
accounts from IRS Form 1040, Schedule 1— Line 12.
DO NOT include student aid, Earned Income Credit, Additional Child Tax Credit, welfare payments,
untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Innovation and
Opportunity Act, educational benefits, combat pay, benefits from flexible spending arrangements (e.g.,
cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels.
If not applicable,
please list “N/A”
$ ____________________
Statement of Support
Please provide additional details explaining how your 2019 housing, utility, food/grocery, miscellaneous, and transportation needs and
expenses were met. Include information such as if your home/vehicle (if applicable) are paid off already, if you have a garden or
livestock you live off of, and any additional information not listed on this form. Because FAFSA information may not reflect your
current situation, please also explain how your family is supporting itself now, including any changes in employment, benefits, income,
or marital status. You may attach a separate sheet. You may NOT list “N/A” here – it will be returned to you as incomplete.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
By signing this worksheet, I/we certify that all of the information reported is complete and correct. I/we also acknowledge that I/we
have read and agree to comply with all verification policies as stated by EWC in the College Catalog and on the EWC website.
Failure to submit information in a timely fashion may result in the application being filed as inactive with no further
consideration and no federal aid for the academic year. Student and spouse (if applicable) must sign:
____________________________________________________ ___________________________________________________
Student’s signature Date Parent signature (if student is dependent) Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
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2021-2022 Household Support Worksheet (V6) (Eastern Wyoming College)

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Completed 4 February 2021

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