Parent(s) Resources –DOCUMENTATION MUST BE SUBMITTED
For any category in which you had no income, benefits or resources please record “0”.
2019 Income (submit documentation)
Income from Work (gross amount) – All pages of IRS Tax Return Transcript
(If no tax return was filed provide proof of non-filing and IRS wage and income Transcript
)
Unemployment Compensation (Form 1099-G)
Social Security Benefits (Form SSA-1099)
Supplemental Security Income (SSI)
Other Monthly Resources
Received
College Refunds (Submit documentation of amounts received during calendar year 2019)
In-Kind Support (Please include any bills paid on your behalf by
someone else, but not considered a loan)
Total Monthly Income/Resources
Total Yearly Income/Resources
2019 Federal/State Benefits Program (Social Services) - If your parent(s) only source of income is from a
Federal/State Benefits Program, you must submit documented proof of at least two of the benefits in this
section received by your parent(s) in 2019.
Did your parent(s) receive Medicaid benefits in 2019? Yes No
(If yes, submit Agency Letter or Form 1095 -B)
Did your parent(s) receive TANF, GA benefits in 2019? Yes No
(If yes, submit Agency Letter) ***Do not send copy of benefit card***
Did your parent(s) receive Food Stamps/Snap benefits in 2019? Yes No
(If yes, submit Agency Letter) ***Do not send copy of benefit card***
Did your parent(s) receive Rental Assistance (Section 8, TRA) in 2019? Yes No
(If yes, submit Agency Letter)
Explanation of Situation (Required)
Include as much detail as possible about how your family covered all expenses listed in Section I for calendar year 2019. An explanation is also
required if few or no expenses were listed in Section I. If you used savings, line of credit, etc. to meet your expenses attach 3 consecutive monthly
statements from those accounts.
I (We) certify that the information above is correct and complete to the best of my (our) knowledge.
Student’s Signature (required): Date: ___________________
Parent’s Signature (required): Date: __________________
PRINT AND SIGN
To submit this form, visit www.njgrants.org select the “Grants” tab then click “Upload Document”.
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evised 1/13/17
Revised 02/16/2021
evised 1/13/17
