PURDUE
UNIVERSITY
®
NORTHWEST
OFFICE OF FINANCIAL AID
2020-2021 Income and Expenses Verification Form (Student)
STUDENT NAME:
DATE:
The income reported on your Free Application for Federal Student Aid (FAFSA) does not give a clear picture of how your
family met their expenses for the 2018 calendar year. Please complete this form so the Office of Financial Aid can evaluate
your eligibility for financial aid. Explain how you were able to cover expenses such as housing, food and utilities.
SECTION 1: Income and Expenses
On your 2020-2021 FAFSA you reported minimal or no income, assets or savings for calendar year 2018. Please list below
all of your income and expenses in 2018.
Complete the entire form. If the answer is zero enter (0) or (N/A).
2018 Income
Monthly
Amount
2018 Expenses
Monthly
Amount
Income from Work (gross amount)
Mortgage/Rent
Business Income
Homeowners/Rental Insurance
Social Security Benefits
Utilities (electric, gas, water)
Unemployment Benefits
Phone (home and cell)
Disability Benefits
Car Payment
Worker’s Compensation
Car Insurance
Alimony
Transportation (fuel, bus, train)
Child Support Received
Food/Groceries
Rental Assistance (TANF)
Medical/Dental Care
Food Stamps (SNAP)
Medical/Dental Insurance
Cash Assistance from
Medications/Prescriptions
Cash Received
Clothing
Money Paid On Your Behalf
Other Expenses
Other Sources
Total Income
Total Expenses
SECTION 2: Explanation of Situation
Please explain your situation. Include as much detail as possible about how your family covered the expenses listed above
for calendar year 2018. An explanation is also required if few or no expenses were listed in Section 1. If you used savings, a
line of credit, etc. to meet your expenses, attach three consecutive monthly statements from those accounts. Use the back
of this form to write your explanation.
SECTION 3: Certification Signatures
Your signature certifies that all the information reported on this form is complete and correct.
Student Signature: _______________________________________Date: _____________________
Office Use Only RRAAREQ: ______VSSI21(R)
Hammond Campus
2200 169
th
Street Hammond, IN 46323
(219) 989-2301 fax (219) 989-2141
1401 S. U.S. Hwy. 421 Westville, IN 46391
finaid@pnw.edu pnw.edu
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