Explanation of Support
Provide information about any other resources, benefits and other amounts received by you and any members of your/
parent’s household. This may include items that were not required to be reported on the FAFSA or other forms submitted
and includes such things as federal veterans’ education, military housing, SNAP, TANF etc.
Name of Recipient Type of Financial Support Annual Amount Received in 2016
If you provided zeros for all the above answers, please explain how you or your parents are supporting the household.
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
Certification and Signatures
Each person signing below certifies that all of the information reported is complete and correct. The parent whose informa-
tion was reported on the FAFSA must sign. We cannot accept digital signatures.
______________________________________________________________________________________________ ______________________________________________________________________________________________
STUDENT’S SIGNATURE DATE PARENT’S SIGNATURE DATE
WARNING: If you purposely give false or misleading information on this form, you may be fined, sentenced to prison, or both.
2019–2020
Household Resources Form
Student Financial Services • 1 Ferncroft Road • Danvers, MA 01923-0840
978-762-4189 www.northshore.edu/paying/financial-services
sfs@northshore.edu
Required (please print) HHES
Student ID#
N 0 0
Last Name: ___________________________________________________________
First Name: ___________________________________________________________
2/27/19
The income reported on the Free Aplication for Federal
Student Aid (FAFSA) appears to be unusually low to support
a household. As a result, we must verify how you are able to
meet your expenses. Report untaxed income and benefits
recieved in calendar year 2017 annual income. Enter 0 if
you or your parent(s) did not receive any untaxed income.
Enter amounts received for the full calendar year.
DO NOT enter monthly amounts.
2017 Untaxed Income Student/Spouse Parent(s)
1. Payments to tax-deferred pension and savings plans (paid directly or withheld from
earnings), including, but not limited to, amounts reported on the W-2 Form in
Boxes 12a through 12d, codes D,E, F, G, H, and S. $ _______________ $ _______________
2. Child support recieved for all children. Do not include foster care or adoption payments
or any amount that was court ordered, but not actually paid. $ _______________ $ _______________
3. Housing, food, and other living allowances paid to members of the military, clergy
and others (including cash payments and cash value of benefits). Do not include the
value of on-base military housing or the value of a basic military allowance for housing. $ _______________ $ _______________
4. Veterans’ non-education benefits such as Disability, Death Pension, or Dependency
& Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances. $ _______________ $ _______________
5. Any other untaxed income or benefits not reported, such as workers’ compensation, disability, etc. Include from
IRS 1040 line 25 (health savings accounts). DO NOT INCLUDE student aid, earned income credit, additional child
tax credit, welfare benefits, untaxed Social Security benefits, Supplemental Security Income, Workforce Investment 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. $ _______________ $ _______________
6. Money received, or paid on your behalf this includes 529 Plans, money paid by
noncustodial parent or money not reported elsewhere on this form. $ _______________ NA
