R
______________________________
Student Rocket Number
Student Last Name
Student First Name
COMPLETE WITH BLACK
INK ONLY. ELECTRONIC
SIGNATURES ARE NOT
ACCEPTABLE.
2016-2017
PARENT EXPENSE AND INCOME WORKSHEET
The income reported on your 2016-2017 Free Application for Federal Student Aid (FAFSA) does not appear sufficient to meet your basic living
expenses (i.e., housing, utilities, food, etc.). In order for the processing of your federal financial aid application to continue, please complete and
return this form to the Office of Student Financial Aid.
List below all expenses incurred by your parent(s) in 2015.
2015 Parent Expenses
List Monthly Amount
What resource was used to pay this expense?
(see list on page 2)
1. Rent or mortgage payment*
$
total per year
2. Car payment
$
total per year
3. Transportation (bus, gas, etc.)
$
total per year
4. Groceries
$
total per year
5. Medical, vision, dental insurance
$
total per year
6. Out of pocket medical expenses
$
total per year
7. Child care expenses
$
8. Natural gas or fuel oil bill
$
total per year
DO NOT LEAVE BLANK
total per year
9. Electric bill
$
total per year
10. Regular telephone and/or cellular telephone bill
$
total per year
11. Cable TV bill/internet bill
$
total per year
12. Miscellaneous personal expenses (hygiene, clothing, etc.)
$
total per year
13. Court ordered child support paid
$
total per year
14. Other (specify)
$
total per year
Total living expenses for one month (add lines 1 - 14)
$
total per year
*If you reported $0 for rent or mortgage payment, please explain what your housing situation was or how this expense was met.
Did your parent(s) earn any income from work in 2015?
Yes
No
Did your parent(s) receive any 2015 W-2s and/or 1099s for income earned from work?
Yes
No
If “Yes,” provide copies of all parent(s) 2015 W-2s and 1099s, even if they were not required to file a federal income tax return for 2015.
Indicate below if your parent(s) received benefits from any of the following programs in 2014 or 2015.
Program
Received in 2014 or 2015?
List Monthly Amount
Supplemental Security Income (SSI) (this is not the same as Social Security
retirement benefits)
 Yes
 No
Free or reduced lunch price
 Yes
 No
Temporary Assistance for Needy Families (TANF)
 Yes
 No
$
Subsidized/public housing (HUD) benefits
 Yes
 No
$
Women, Infants, and Children Program (WIC) benefits
 Yes
 No
$
Supplemental Nutrition Assistance Program (SNAP) benefits
(formerly known as Food Stamps)
 Yes
 No
$
List names of persons living in the household who received SNAP
benefits in 2014 or 2015:
$
LEAVE BLANK
List SNAP recipients’ relationship to student:
1.
2.
3.
CONTINUE TO PAGE 2.
PINEX1
1
20151221
R
______________________________
_______________________
Student Rocket Number
Student Last Name
Student First Name
Your parent(s) may have additional resources other than earnings from employment. If so, some types of resources must be
considered when determining your federal financial aid eligibility. List below amounts for all forms of additional resources received
by your parent(s) in 2015.
2015 Parent Income/Resources
List Monthly Amount
1. Income from work (gross amount)
$
2. Spouse’s income from work (gross amount)
$
3. Resources from parents or relatives
$
4. Resources from boyfriend/girlfriend
$
5. Resources from partner/life partner
$
6. Unemployment benefits
$
7. Disability benefits
$
8. Child support received
$
9. Business, rental, or farm income
$
10. Alimony
$
11. Trust fund income
$
12. Interest/dividend income
$
13. Social Security retirement benefits
$
14. Social Security Disability benefits (SSI)
$
15. Public assistance (including TANF)
$
16. Free or reduced price lunch for children
$
17. Veteran’s benefits (non-education)
$
18. Financial aid refund
$
19. Other (specify)
$
Total income and resources for one month (add lines 1 – 19)
$
Office Use Only
DO NOT
LEAVE
BLANK
Please add any clarifying comments regarding your situation that will help with our review.
It is reasonable to expect that all individuals have basic living expenses that must be paid in order to survive. If your total 2015 expenses appear
low and/or your total income/resources appear to be too low to reasonably support yourself (and your family, if applicable), an additional
explanation is required.
Certification Statement: By signing this worksheet, I (we) certify that all of the information reported on this worksheet, used to determine
eligibility for federal financial aid, is complete and correct. WARNING: If you purposely give false or misleading information on this worksheet,
you may be fined, sentenced to jail, or both.
Parent Signature
Student Signature
Date
Date
Questions? Please contact Rocket Solution Central (RSC) at 419.530.8700.
PINEX1
2
RETURN TO:
The University of Toledo
Office of Student Financial Aid
2801 W. Bancroft St., Mail Stop 314
Toledo, OH 43606-3390
*** Faxed documents will not be accepted.***
20151221