MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

STUDENT INCOME VERIFICATION DATE: December 27, 2013

A. STUDENT IDENTIFICATION DATA (COMPLETED BY FSD)
OFFICE	STUDENT NAME
ADDRESS	DCN	SOCIAL SECURITY NUMBER - -
CITY, STATE, ZIP	CASE NAME	CASE DCN
PHONE - -	CASE ADDRESS
NAME AND ADDRESS OF INSTITUTION/SCHOOL
INSTRUCTIONS: The information on this form will be used to verify the income and expenses for the student named above. Please complete Section C and return to the Family Support Division office. PLEASE FAX RESPONSE TO: - -
B. I AUTHORIZE THE RELEASE OF INFORMATION REGARDING MY STUDENT STATUS, FINANCIAL AID, AND EDUCATIONAL EXPENSES TO THE MISSOURI FAMILY SUPPORT DIVISION.
Student Signature:	Date:
C. STUDENT INCOME/EXPENSE DATA (COMPLETED BY POST SECONDARY SCHOOL OFFICIAL)
1. DOES YOUR SCHOOL /INSTITUTION REQUIRE A GED OR HIGH SCHOOL DIPLOMA FOR ADMISSION? YES NO
NO. HRS. ENROLLED	PERIOD OF TIME
2. THE STUDENT IS ENROLLED FOR: FULL-TIME ATTENDANCE HALF-TIME ATTENDANCE	START DATE	END DATE
3. STUDENT INCOME-PLEASE LIST ALL INCOME THE STUDENT RECEIVES THROUGH YOUR INSTITUTION AND ALL EXPENSES THE INCOME IS INTENDED TO COVER. THIS INFORMATION AIDS US IN ALLOWING ALL APPLICABLE DEDUCTIONS.
TYPE OF GRANT, LOAN, SCHOLARSHIP, (PELL, SEOG, STAFFORD, ETC.) LIST EACH SOURCE SEPARATELY	EDUCATIONAL EXPENSES THE INCOME IS INTENDED TO COVER	FUNDED THROUGH TITLE IV? (Even Partially)	REPAYMENT DEFERRED?	DATE PAID OR TO BE PAID	COVERED PERIOD
1. AMOUNT $	Tuition Transp Fees Loan fees/ insurance Supplies premiums Books Other	YES NO	YES NO
2. AMOUNT $	Tuition Transp Fees Loan fees/ insurance Supplies premiums Books Other	YES NO	YES NO
3. AMOUNT $	Tuition Transp Fees Loan fees/ insurance Supplies premiums Books Other	YES NO	YES NO
IF THERE ARE MORE THAN 3 INCOME SOURCES, PLEASE SUPPLY ADDITIONAL INFORMATION ON BACK OF FORM.
5. IS THE STUDENT PARTICIPATING IN A FEDERALLY FINANCED TITLE IV WORK-STUDY PROGRAM? YES NO COMPLETE THE CHART BELOW FOR ALL WORK STUDY INCOME RECEIVED.
RATE OF PAY	HOURS WORKED	DATE PAID	PAYROLL CYCLE (WEEKLY, BI-WEEKLY, ETC.)	EDUCATION EXPENSES (The income is intended to cover)
Tuition Transportation Fees Loan fees/insurance
Supplies premiums Books Other
6. Are there any other known sources of income either available or being received YES NO by the STUDENT? If yes, please explain. (USE REVERSE SIDE.)
SCHOOL OFFICIAL’S SIGNATURE and PRINTED NAME/TITLE DATE
MO 886-1748(01-2014)	IM-108 (01-2014)