2023-2024 Income and Benefits Verification

Name(Required)

First Middle Last Suffix

Student ID#(Required)

Phone Number(Required)

Based on the 2021 Federal Guidelines the amount of income you or your parent (s) reported on the FAFSA appears unusually low in which to support yourself or a family. You or your parent(s) must complete this form and return it to the Financial Aid Office. We need to know that we completely understand your situation and have an accurate picture of how you and your family met their living expenses. This worksheet must be completed before we can verify your eligibility and disburse your federal financial aid. We understand this may be a sensitive issue and we want you to know we respect your privacy; however, we are required to verify this information on the FAFSA. Thank you for your understanding.

When this form is complete bring, scan, mail or fax this form with all required documentation to the Financial Aid Office at 219 Rock Street, Bluefield WV 24701, FAX# (304)327-4153. You can also complete and submit this form online at “bluefieldstate.edu”, under quick links, financial aid and 2023-2024 financial aid documents. ALL supporting documentation must be mailed, faxed or scan to the financial aid office. Include your name and student ID# on all documentation submitted.

Parent Average Monthly Expenses

Rent/Utilities

Food

Child Care

Miscellaneous

Hidden

Total Parent Monthly

Parent Resources (Check ALL that apply)

Note that Government Aid includes Supplemental Nutrition Assistance Program (SNAP), Infants & Children (WIC), Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), Sections 8 (HUD), Military Benefits (including housing)

Government Aid

Child support received

Unemployment

Worker’s compensation

Income from employment

Other untaxed income

Money received, or aid on your behalf, not reported elsewhere

Government Aid Amount(Required)

Child Support Amount(Required)

Unemployment Amount(Required)

Worker's Compensation Amount(Required)

Income from employment Amount(Required)

Other untaxed income Amount(Required)

Money received, or aid on your behalf, not reported elsewhere Amount(Required)

Hidden

Total Parent Resources

Student (spouse if married) Average Monthly Expenses

Rent/Utilities

Food

Child Care

Miscellaneous

Hidden

Total Student Monthly

Student (spouse if married) Resources (Check ALL that apply)

Government Aid

Child support received

Unemployment

Worker’s compensation

Income from employment

Other untaxed income

Money received, or aid on your behalf, not reported elsewhere

Government Aid Amount(Required)

Child Support Amount(Required)

Unemployment Amount(Required)

Worker's Compensation Amount(Required)

Income from Employment Amount(Required)

Other untaxed income Amount(Required)

Money received, or aid on your behalf, not reported elsewhere Amount(Required)

Hidden

Total Student Resources

If the above information is ALL zeros or does not sufficiently explain how the household living expenses were met in 2021, you must provide a detailed statement below that will resolve what appears to be conflicting or incomplete information.

Please include any excluded items (with amounts) from the above table. These amounts will not be included nor counted against your FAFSA EFC, they will help explain how the household survived on so little reported income.

Student Signature(Required)

By signing this worksheet, you certify that all of the information given is complete and correct. You understand that you may lose consideration for financial aid if you do not submit ALL verification documents in a timely manner.

Parent Signature(Required)

Parent Average Monthly Expenses

Student (spouse if married) Average Monthly Expenses

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