Free 42755.FH11 - Indiana

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REQUEST FOR STUDENT INCOME AND EXPENSES
State Form 42755 (R5 / 1-08) / FI 2203 *SOCIAL SECURITY NUMBER This State agency is requesting disclosure of your Social Security number, under IC 4-1-8-1, in order to perform its statutory function. Disclosure is mandatory and this form will not be processed without it.

Date (month, day, year)

NOTICE OF CONFIDENTIALITY The information obtained on this form is confidential under state and federal regulations, including 470 IAC 1-2-7, 470 IAC 1-3-1, 470 IAC 6-1-1, 405 IAC 1-1-12, 45 CFR 205.50, 7 CFR 272.1 (c), and 42 CFR 431.300. This information will not be released except as permitted or required by law or with the consent of the applicant / recipient whose signature appears below. RE: Name of student Case number Case name (if different)

TO: (name and address of school)

Dear Sir or Madam: The student referenced above is part of a household which has applied for or currently receives benefits from one or more of the following programs: Temporary Assistance for Needy Families (TANF), Food Stamps and/or Medicaid. In order to determine the eligibility and/or benefit level for this household, information concerning financial aid must be obtained from your office. This information will be used only for the purpose of determining if any income must be included in budgetary calculations required by these programs. Please complete the appropriate information requested on the reverse side of this letter and return this form as soon as possible to the County Office of Family Resources indicated below. Thank you for your cooperation in this matter. Sincerely,
Signature of worker ID number Telephone number

(

)

I hereby authorize __________________________________________________________________________ to release information about my
Name of institution

financial aid which is necessary to determine my household's eligibility for Food Stamps / TANF / Medicaid.

Signature of student

*Social Security number

xxx - xx -

RETURN TO: County Office of Family Resources
Address (number and street) City, state and ZIP code

ATTENTION:

FOLD

FOLD

ATTENTION: Financial Aid Office

Name of student

*Social Security number

I. ENROLLMENT The student attends: less than 1/2 time 1/2 time or more Yes The student is enrolled in a No graduate or undergraduate program Yes No

Is a GED or diploma required for enrollment in school?

If No, in student's curriculum?

II. TYPE OF STUDENT ASSISTANCE / EXPENSES Date Income Disbursed to the Student Months Involved in Period Provided for (whole or part) Expenses Total Amount Tuition Mandatory Fees Charged by School Origination & Insurance Fees on Loan

Name of Assistance

PELL Grant ___ / ___ / ___ ______ thru _______ $ $ $ $

Educational loan Name: _______________

___ / ___ / ___

______ thru _______

$

$

$

$

Other Name: ________________

___ / ___ / ___

______ thru _______

$

$

$

$

Other Name: ________________

___ / ___ / ___

______ thru _______

$

$

$

$

VA Benefits Name: ________________

___ / ___ / ___

______ thru _______

$

$

$

$

III. WORK STUDY PARTICIPATION
Date participation begins (month, day, year) Date participation ends (month, day, year)

Paid on ___________________________________________ or
Day of week / date(s) during month

Pay date varies Gross amount varies Semi-monthly Monthly

Gross amount received is $ ___________________________ or Paid: Weekly Bi-weekly

IV. ADDITIONAL EXPENSES Please list below any amount of assistance listed in Section II and III that is earmarked for fees, books, supplies, tranportation and other miscellaneous personal expenses (other than living expenses; shelter, clothing and food) incidental to attending your institution. If funds are earmarked for dependent care please list separately. Expense Months Involved ____________________ thru ____________________ ____________________ thru ____________________ ____________________ thru ____________________ ____________________ thru ____________________ ____________________ thru ____________________
Signature of person completing this form Title

Amount $ $ $ $ $
Date (month, day, year)