PURDUE
UNIVERSITY
®
NORTHWEST
2021-2022 Income and Expenses Verification Form (Student)
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 2019 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 2021-2022 FAFSA you reported minimal or no income, assets or savings for calendar year 2019. Please list below
all of your income and expenses in 2019.
Complete the entire form. If the answer is zero enter (0) or (N/A).
2019 Income
2019 Expenses
Income from Work (gross amount)
Homeowners/Rental Insurance
Utilities (electric, gas, water)
Transportation (fuel, bus, train)
Medications/Prescriptions
Money Paid On Your Behalf
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 2019. 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: _______________________________________PUID: _____________________
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2200 169
th
Street Hammond, IN 46323
(219) 989-2301 fax (219) 989-2141
1401 S. U.S. Hwy. 421 Westville, IN 46391
(219) 785-5460 fax (219) 785-5653
