Financial Disclosure For Reasonable And Affordable Rehabilitation Payments Form - U.s. Department Of Education Page 3
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5SECTION 7: SPOUSE’S UNTAXED ASSISTANCE PAYMENTS INFORMATION – To be completed if you completed SECTION 5.
Provide the following information about your spouse’s untaxed assistance payments he or she is currently receiving, using the instructions provided in Section 4
of this form. You must attach supporting documentation for each source of your spouse’s untaxed assistance payments consistent with the
instructions in Section 4.
Weekly
Amount of Assistance Payment (First Source):
_______________________
Monthly
Other:
___________________________
Weekly
Amount of Assistance Payment (Second Source):
________________________
Monthly
Other:
___________________________
Weekly
Amount of Assistance Payment (Third Source):
________________________
Monthly
Other:
___________________________
SECTION 8: FAMILY SIZE AND ADJUSTED GROSS INCOME
Provide the following information about the number of people in your family. Your family size includes you, and if applicable, your spouse, and any children
(including unborn children) who receive more than half of their support from you. Your family size also includes anyone who lives with you and receives more than
half of their support from you (and who will continue to receive this support for at least the remainder of the calendar year). Support includes, but is not limited to,
money, gifts, loans, housing, food, clothes, car, medical and dental care, and payment of college costs.
•
For example, if you are unmarried and live alone, your family size is one. If you and your spouse have two children and provide financial support for a
live-in relative, your family size is five.
Family Size
Provide a copy of your most recently filed U.S. income tax return or IRS tax transcript that reflects your adjusted gross income and list that amount below. If you
were not required to file a tax return, leave this item blank.
Adjusted Gross Income
SECTION 9: REASONABLE AND NECESSARY MONTHLY EXPENSES
Provide the following information about the reasonable and necessary expenses you and, if applicable, your spouse or any dependents, incur each month. If a
cost is incurred more or less often than monthly, write the average amount spent each month. Do not include a single expense in more than one applicable
category. For example, do not include the expenses paid for health insurance under both “Health Care” and “Insurance”. If you have no expenses under a
category, enter “Zero” or “0” for that category. The holder of your loan may request supporting documentation for any of these categories and may use its
discretion in determining the amount of an expense that is reasonable using a fact-based standard such as the IRS national standards.
(1) For “Food”, include the amount spent on food, even if purchased using the Supplemental Nutrition Assistance Program (SNAP) (food stamps).
Amount spent on Food
(2) For “Housing”, include the amount spent on housing and shelter, such as rent, required security deposits, and mortgage payments (inclusive of
principal, interest, taxes, and homeowner’s insurance if not included in (6) below).
Amount spent on Housing
(3) For “Utilities”, include the amount spent on housing-related utility bills, such as gas, electric, water, sewer, trash, and recycling.
Amount spent on Utilities
(4) For “Communication”, include the amount spent on basic communication expenses, such as basic telephone and internet expenses.
Amount spent on Communication
(5) For “Medical and Dental”, include the amount spent on necessary medical and dental costs, such as medically necessary prescription and
nonprescription medication, and medically necessary nutritional supplements. Do not include any costs relating to medical or dental insurance
premium payments.
Amount spent on Medical and Dental
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