Financial Aid Office SUNY Plattsburgh 101 Broad Street Plattsburgh, NY 12901-2681
Tel: (518) 564-2072 Toll-Free: (877) 768-5976 Fax: (518) 564-4079 email: finaid@plattsburgh.edu
Revised: 12/01/2019 YHSUPP
EOP HOUSEHOLD SUPPORT WORKSHEET FOR DEPENDENT STUDENT 2018
Student Name: ___________________________ Banner ID or NetID: ____________________________
On your EOP Application you indicated that your household has zero ‘0’ income or an income that appears too
low to support the number of household members you have reported. Please use the form below to clarify
your household’s financial support for 2018: between January 1, 2018 and December 31, 2018. This
information is necessary in establishing your financial eligibility for EOP.
Complete all items. If items are left blank, this form will not be processed.
Child support received (total annual amount)
Yes No
Amount per year: $
Alimony received
Yes No
Amount per year: $
SNAP (formerly known as food stamps)
Yes No
Amount per year: $
Home energy assistance
Yes No
Amount per year: $
Housing Assistance
Yes No
Amount per year: $
TANF (
“Family Assistance or “Safety Net Assistance”
)
Yes No
Amount per year: $
Free/Reduced school lunch
Yes No
Amount per year: $
Recipient:
Relationship to applicant:
Unemployment income
Yes No
Amount per year: $
Recipient:
Relationship to applicant:
Social Security Disability (SSD)
Yes No
Amount per year: $
Recipient:
Relationship to applicant:
Supplemental Security Income (SSI)
Yes No
Amount per year: $
Recipient:
Relationship to applicant:
Survivors Benefits
Yes No
Amount per year: $
Recipient:
Relationship to applicant:
Military and Veteran’s Benefits
Yes No
Amount per year: $
Recipient:
Relationship to applicant:
“Gifts” from family, friends or community
Yes No
Amount per year: $
OTHER
Yes
No
Please attach a statement detailing your household
circumstances.
For any benefits that you reported below, attach a letter or summary statement from the agency that
provides the benefits. Attachments must verify the annual amounts reported above for 2018.
By signing this worksheet, I certify that all the information reported is complete and accurate. If false or
misleading information is purposely provided on this worksheet, I understand that my application or acceptance
to EOP will be revoked.
Student Ink Signature Date
Parent Ink Signature If Dependent Date
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