Form V03 - Financial Disclosure Statement - U.s. Department Of Education printable pdf download

Form V03 - Financial Disclosure Statement - U.s. Department Of Education

U.S. Department of Education

Financial Disclosure Statement

To evaluate a hardship claim, the U.S. Department of Education (the Department) compares the

expenses you claim and support against averages spent for those similar expenses by families of

the same size and income as yours. The Department considers proven expenses as reasonable up

to the amount of these averages. If you claim more for an expense than the average spent by

families like yours, you must provide persuasive explanation why the amount you claim is

necessary. These average amounts were determined by the Internal Revenue Service (IRS) from

different government studies. You can find the average expense amount that the Department uses

and then search for “Collection Financial Standards.”

at the following Web site:

 Complete all items. Do not leave any item blank. If the answer is zero, write zero.

 Provide documentation of expenses. Expenses may not be considered if you do not

provide documents supporting the amounts claimed.

 Disclose and provide documentation of household income.

 Failure to provide this information and documentation may result in a denial of your claim of

financial hardship.

Income

Your Name: ________________________ Your Social Security No.: _________________

Address: __________________________________________________________________

__________________________ Phone: ________________________________

__________________________ Country: ______________________________

Current Employer: ___________________Date Employed: ________________________

Employer Phone: ___________________Present Position: ________________________

$_________  Weekly  Bi-Weekly  Monthly  Other

Gross Income:

_________

$_________  Weekly  Bi-Weekly  Monthly  Other

Net Income:

_________

ENCLOSE: COPY OF YOUR TWO MOST RECENT PAY STUBS AND

COPIES OF MOST RECENT W-2s AND 1040, 1040A, 1040EZ or other IRS FILING

Number of dependents: __________ (including yourself)

 Married  Single  Divorced

Marital status:

Your spouse’s name: __________________ Spouse’s SSN: _________________________

$_________  Weekly  Bi-Weekly  Monthly  Other ____________

Gross Income:

$_________  Weekly  Bi-Weekly  Monthly  Other ____________

Net Income:

ENCLOSE: COPY OF TWO MOST RECENT PAY STUBS AND

COPIES OF MOST RECENT W-2s AND 1040, 1040A, 1040EZ or other IRS FILING

v03 (280) Rev. 09/2011

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FDS DCSI-009

Form V03 - Financial Disclosure Statement - U.s. Department Of Education

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