Verification Of Additional Household Resources
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DEP
Financial Aid Services
243 Whitmore Administration Building
181 Presidents Drive, Amherst, MA 01003
Phone: 413-545-0801
Fax: 413-545-1700
Web: umass.edu/umfa
Email: fi naid@fi naid.umass.edu
2015-2016 Verifi cation of Additional Household Resources
PART I: STUDENT INFORMATION
Name:_______________________________________________________________________________________ SPIRE ID:____________________________
Last
First
Middle
Home Address:______________________________________________________________________________________________________________________
# Street
City
State
Zip
Date of Birth: _________/_______/_____________
Phone Number: (
) _________ - _______________
PART II: HOUSEHOLD RESOURCES INFORMATION
Please report below any amount received in 2014 by you and your parent(s). Report total amount received for the entire year.
Do not include student fi nancial aid received. You must check yes or no for each question in order for the form be considered
complete.
Did you or your parent(s)...
Parent(s)
Student
...Receive money or have bills paid by someone not in the household?
• No
•Yes Amount $________
• No
•Yes Amount $________
...Receive income or benefi ts from the government/state in any of the following forms?
● Social Security Benefi ts
•Yes Amount $_______
• No
•Yes Amount $________
• No
● Worker’s Compensation
•Yes Amount $________
• No
•Yes Amount $________
• No
● TAFDC or EAEDC
•Yes Amount $________
• No
•Yes Amount $________
• No
● Fuel, Heat, or Energy Assistance
•Yes Amount $________
• No
•Yes Amount $________
• No
● SNAP or WIC
•Yes Amount $________
• No
•Yes Amount $________
• No
● Section 8, MRVP, or AHVP
•Yes Amount $________
• No
•Yes Amount $________
• No
● Railroad Retirement Benefi ts
•Yes Amount $________
• No
•Yes Amount $________
• No
● Black Lung Benefi ts
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive cash payment for food, housing, or living expenses as a
member of the military or clergy?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive alimony?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive child support?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive tax-exempt interest income?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive foreign income?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive any other forms of income? if yes,
explain: ____________________________________________
•Yes Amount $________
• No
•Yes Amount $________
• No
...Make withdrawals from an IRA, pension, or other retirement account?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Pay into a health saving account?
•Yes Amount $________
• No
•Yes Amount $________
• No
*FDRESE*
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