Monthly Income And Expense Verification Form Dependent 2015-16 - Vcu - Virginia Page 2
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2NAME ______________________________________________________________
Last
First
Student ID Number
MI
SECTION B: EXPENSES
The form will be returned if you leave a field blank. If the answer is zero enter “0” or “N/A.”
2014 Parent Expenses
Amount Per
2014 Student Expenses
Amount Per
Month
Month
Rent/Mortgage
Rent/Mortgage
Utilities (electric, water, gas)
Utilities (electric, water, gas)
Telephone/Cell Phone
Telephone/Cell phone
Medical/Dental health insurance
Medical/Dental health insurance
Car payment
Car payment
Car insurance
Car insurance
Food/Groceries
Food/Groceries
Transportation (fuel, bus, train)
Transportation (fuel, bus train)
Child Support
Child Support
Other expenses
Other expenses
TOTAL EXPENSES =
TOTAL EXPENSES =
SECTION C: EXPLANATION OF SITUATION (Required)
Please explain your situation. Include as much detail as possible about how your family covered housing, utilities and other living
expenses for calendar year 2014. An explanation is also required if few or no expenses were listed in Section B. If you used savings,
line of credit, etc. to meet your expenses attach three consecutive monthly statements from those accounts.
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SECTION D: CERTIFICATION SIGNATURES
I/We certify that all information reported is complete and accurate to the best of my ability. I/We understand that any false statement
or misrepresentation may be cause for reduction and/or repayment of federal, state or institutional financial aid.
Student Signature _______________________________________________________ Date _________________________
(Required)
Parent Signature ________________________________________________________ Date _________________________
(Required)
Office of Financial Aid
Grace E. Harris Hall Student Service Center
1015 Floyd Ave., 1st Floor
P.O. Box 843026
Richmond, VA 23284-2520
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(804) 828-1550
Fax (804) 827-0060
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VCU is an EEO/AA institution. ENR1314-121
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