Request For Independent Status Page 3
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4IV. MONTHLY EXPENSES AND INCOME WORKSHEET (Complete using 2015 information):
2016 EXPENSES: List your monthly expenses for 2016 below and the name of the person who
provides payment for them.
Expense
Monthly Cost
Who Pays or Provides the Expense
Housing
$
Utilities
$
Food
$
Child Care or Dependent Care
$
Transportation
$
Medical/Insurance
$
Personal (clothing, toiletries, etc.)
$
Other
$
TOTAL EXPENSES:
$
2016 INCOME: List your monthly income for 2016 as specified below, and list the source of that income by name
(examples: self-employed, employer’s name, trust fund, etc.).
Type of Income
Monthly Income
Source(s)
Wages
$
Interest/Dividends
$
Untaxed Income (social security,
$
unemployment compensation, etc.)
Cash Support/Gift
$
Federal Work-Study
$
TANF
$
Other
$
TOTAL INCOME:
$
HAVE YOU COMPLETED ALL OF THE DOCUMENTATION REQUIREMENTS FOR YOUR SITUATION?
Continue to Section V on the next page.
937-766-7866
• finaid@cedarville.edu • cedarville.edu/finaid
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