Custodial Parent Monthly Household Expenses

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Financial Aid Services
243 Whitmore Administration Building
181 Presidents Drive, Amherst, MA 01003
15-16
Phone: 413-545-0801
Fax: 413-545-1700
Web: umass.edu/umfa
Email: fi naid@fi naid.umass.edu
CUSTODIAL PARENT MONTHLY HOUSEHOLD EXPENSES
Student Name: ________________________________________________________ SPIRE ID:__________________________
Custodial Parent Name: _________________________________________________ Phone Number: (
) ______- ________
__
Custodial Parent Home Address: ___________________________________________________________________________
The parent the student lives with must complete, sign and return this form to Financial Aid Services.
In order to continue review of the fi nancial aid application for the student listed above, you must provide the information requested below.
List the amount of all your household monthly expenses (include expenses for all family members):
Rent/Mortgage Payment:
$_________________
Home/Renters Insurance:
$_________________
Property taxes:
$_________________
Town/City Water:
$_________________
Town/City Sewer:
$_________________
Heating Fuel:
$_________________
Electricity:
$_________________
Lawn Care/Snow removal:
$_________________
Home Repairs:
$_________________
Cable:
$_________________
Internet:
$_________________
Home Telephone:
$_________________
Cell Phone:
$_________________
Food/Groceries:
$_________________
Laundry/Cleaning supplies:
$_________________
Health Insurance (medical/dental)
$_________________
Medicines and copays:
$_________________
Credit Cards Payments:
$_________________
Clothing:
$_________________
Car Payment:
$_________________
Car Insurance:
$_________________
Car Repairs/Car Related Expenses:
$_________________
Vacation and Travel:
$_________________
Entertainment and Dining:
$_________________
Gifts:
$_________________
Memberships:
$_________________
Other: explain_____________________________
$_________________
I certify that the information provided is true and accurate. If I purposely give false or misleading information to Financial Aid Services,
I may be fi ned, sentenced to prison, or both.
Please be aware Financial Aid Services is obligated
to report fi nancial aid applicants that purposely
_________________________________________________________
misreported information or altered documentation to
Custodial Parent Signature
Date
obtain federal funds to the Offi ce of Inpector General
for investigation and prosecution.
Document must be signed with a real signature. Digital signatures are not accepted.
Fax completed, signed form to: 413-545-1700
or email completed, signed form to: fadocs@fi naid.umass.edu
(Attachments must be a standard image fi le, or in one of the following fi le formats: .doc, .docx, .pdf)
*FVCHH*

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