HTML Preview Proof Of Other Income Form page number 1.


MAIL OR RETURN TO:
James Sprunt Community College, Attn: Financial Aid Office, PO Box 398, Kenansville, NC 28349
2014 2015
Proof of Other Income Form
Your Bridge to Success
Student Name:________________________________________ ID:____________________
If anyone in the household receives Social Security Benefits, DCI, SSI, Disability, or any other untaxed
income/benefits, please complete and return this document. Attach a copy of your award letter.
I, (Student/Spouse/Parent)_______________________________, received untaxed income/benefits during 2013.
(circle one) (Print your full name)
I receive income from:
Social Security Benefits $ ____________________
Death & Indemnity Compensation (DIC) $ ____________________
Supplemental Security Income (SSI) / Disability $ ____________________
VA Disability $ ____________________
Other: _________________ $ ____________________
********************* You must sign this form in the presence of a notary. *******************
By signing this form, you agree to provide information that will verify the accuracy of your information,
if requested. If you purposely give false or misleading information, you will be referred to the United
States Department of Education’s Inspector General. If you purposely give false or misleading
information in order to qualify for Title IV funds, you may be fined, sent to prison or both.
___________________________________________________ Date__________________________________
Student’s Signature
___________________________________________________ Date__________________________________
Spouse -OR- Parent Signature
County: _________________________
State: ________________________________________ Notary Seal
My commission expires: _________________________
Sworn to and subscribed before me this, the ________ day of_____________________, 20______.
Notary’s Signature: _______________________________________________________________
Please Print Notary Name:__________________________________________________________
DOWNLOAD HERE


Hire character. Train skill. | Peter Schutz