Confidential Financial Information Form
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1CONFIDENTIAL FINANCIAL INFORMATION
The information in this statement is used to determine economic need and eligibility for enrollment in the SCSEP Program.
This information is required by Federal Regulation.
Monthly Income
Annual
Other
EXCLUDABLE INCOME
Amounts
INCLUDABLE INCOME
Participant Spouse Family
Total
Public Assistance Payments
Members Per Month
25% Gross Social Security
Wages or Salary from Employment
Disability (Any Kind)
Self Employment Income
Lottery Winnings/Dividend/Interest
Retirement Pensions
Worker's Compensation
75% of Gross Social Security
Black Lung Payments
Railroad Retirement
Supplemental Security Income (SSI)
Federal, State, or Local Government
Personal Property Sales
Military Retirement
Unemployment Compensation
Other Regular Pensions
Reverse Mortgages
Annuity (Insurance or Trust)
IRA's
Rental Income
One Time Unearned Income
Alimony
Title V Earnings
Regular Cash Support
Volunteer Payments
(from relatives, friends, etc)
Capital Gain/Asset Draw Down
Other: Please List Below
Native American Payments up to $2,000.00
Non Cash Income
Inheritance/Sale of Property
World War II Interness Payments
Total Last 6 Months
Alaska Permanent Fund Dividends
Total Last 12 Months
I declare that the information reported on this statement, to the best of my knowledge and belief is true, correct and complete.
Signature: __________________
Date:________ SCSEP Representative: _______________________ Date: ___________
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