2012-2013 Income & Resource Certification Form (Student)

              FSINCR 2012-2013 Student Income Resource.docx 4/3/2012
Rose State College
Office of Student Financial Aid and Scholarships
(405) 733-7424
(405) 736-0359 Fax
2012-2013 Income & Resource Certification Form (Student)
Student Name: __________________________ Student ID# ____________
The Office of Student Financial Aid and Scholarships has completed an initial review of your 2012-2013 application for assistance. Before we may proceed with our review, additional information is necessary.
Complete all items on this form and attach documentation to support your responses. The completed form and documentation should be returned to this office.
Did you and/or your spouse file a 2011 federal tax return?
____YES ____NO If yes, attach a copy of your 2011 IRS tax transcript.
During 2011, did you and/or your spouse have income not reported on the 2011 tax return?
____YES ____NO If yes, attach documentation for 2011.
Are you married?
____YES ____NO If yes, what is the date of marriage?
Are you legally separated from your spouse?
_____YES ____NO If yes, attach a copy of your legal separation papers.
Are you divorced?
____YES ____NO If yes, what was the date of the divorce? Also, attach a copy of the decree.
FSINCR 2012-2013 Student Income Resource.docx 4/3/2012
Explain briefly how you lived in 2011 on the income reported on your application.
Be sure to explain and document any unusual circumstances.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please complete the following section to show where and with whom you lived from January 2011 to December 2011.
Name
Relation
Address
Dates
Are you currently employed? ____YES ____NO
If yes, where?____________________ When did you start? _________________
What are your monthly earnings (before taxes)?___________________________
Listed below are some common household expenses. Please explain the amount of this expense for YOU each month during 2011 --- and how you met this expense. Be specific regarding the source of support to pay the expense. Include expenses for YOU only.
Type of Expense
Amount of Expense
How Expense Was Paid
Housing
Name on Lease? Y or N
Utilities
Food
Clothing
Medical
Transportation (Gas or like expense)
Personal/Misc
I certify the information reported on this form is accurate and complete. I understand I may be asked to verify all of the information reported on this form and on my application.
Student Signature:___________________________________________Date:______________
Current Address:_______________________________________________________________