SECTION III FAMILY INCOME DETAIL – We will likely ask you to provide proof of household income before we award you Workforce Solutions financial aid. Complete this worksheet by listing your household members and checking the income sources that apply to each member within the most recent 26 weeks. If you are applying only for child care assistance, check income sources that apply for the most recent 13 weeks. Public Capital Social Security Lottery Assistance Gains/Loss (Old Age, Wages/ Self- UI Child Interest winnings (TANF, SSI, or Rental Survivors, Workers Household Member with Income Salary Employment Payments Support Dividends Retirement over $600 Inheritance SNAP, etc.) Income Disability) Compensation Acceptable Documentation: (Attach an Self-employment verification form IRS form 1040 Schedule D for capital gains The information submitted here is complete and appropriate document to support each accurate to the best of my knowledge. Family or business financial records Retirement/Pension statement income source for each Household Member) Award letter from Veterans Affairs Quarterly estimated tax for self-employed Pay stubs persons (Schedule C) Print Name Bank statement- cannot be used in lieu of Employment/Income Verification form (new pay stubs or income verification Supplemental Security Insurance statement job or paid in cash only) (must include benefit type) IRS form 1099-DIV, -INT, for dividends or Workers Compensation documentation/ Signature interest statement Social Security statement Date
SECTION III – FAMILY INCOME DETAIL We will likely ask you to provide proof of household income before we award you Workforce Solutions financial aid. Complete this worksheet by listing your household members and checking the income sources that apply to each member within the most recent 26 weeks. If you are applying only for child care assistance, check income sources that apply for the most recent 13 weeks. Household Member with Income Wages/ Salary Self- Employment UI Payments Child Support Interest Dividends Retirement Lottery winnings over $600 Inheritance Public Assistance (TANF, SSI, SNAP, etc.) Capital Gains/Loss or Rental Income Social Security (Old Age, Survivors, Disability) Workers Compensation Acceptable Documentation: (Attach an appropriate document to support each income source for each Household Member) Pay stubs Employment/Income Verification form (new job or paid in cash only) Workers Compensation documentation/ statement Social Security statement Self-employment verification form Family or business financial records Award letter from Veterans Affairs Bank statement- cannot be used in lieu of pay stubs or income verification IRS form 1099-DIV, -INT, for dividends or interest IRS form 1040 Schedule D for capital gains Retirement/Pension statement Quarterly estimated tax for self-employed persons (Schedule C) Supplemental Security Insurance statement (must include benefit type) The information submitted here is complete and accurate to the best of my knowledge. Print Name Signature Date
Financial-Aid-Application-E.docx