Boston (T) 617.732.2864 (F) 617.732.2082 Worcester (T) 508.373.5633 (F) 508.755.1282 Manchester/Online (T) 603.314.1729 (F) 603.314.0213 2014 - 2015 Parent Expense & Resource Worksheet Student Name:____________________________________________ MCPHS ID:#___________________ Please complete this worksheet by providing the following: expense and resource information for the 2013 calendar year, household information for 2013, and certification of the information provided. ENTER “0” or “N/A” WHERE APPROPRIATE - DO NOT LEAVE ANY ITEM BLANK. P P P Expenses Amount per Month Housing Costs Rent or Mortgage Utilities (monthly average) Gas, Heat, and Electric Water Telephone and Cell Phone Other (specify) Transportation Gas Car Payments and Insurance Public Transportation Other (specify) Other Expenses Food Clothing Recreation/Entertainment Medical Child Care Other (specify) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Expenses: Resources Parent 1 Gross Income from Work Parent 2 Gross Income from Work Student Gross Income from Work (if used for household) Untaxed Income (attach itemized list with student ID#) Other (attach itemized list with student ID#) Amount per Year (Amount per Month x 12) $ $ $ $ $ $ $ $ $ $ $ Total Resources: $ ADDITIONAL INFORMATION MAY BE NEEDED: If your total expenses were greater than your total resources, please write a detailed explanation of how you were able to meet your financial obligations in 2013 and attach to this document. Please include MCPHS ID# on additional paperwork. ***Please return completed form to the Office of Student Financial Services*** Boston (T) 617.732.2864 (F) 617.732.2082 Worcester (T) 508.373.5633 (F) 508.755.1282 Manchester/Online (T) 603.314.1729 (F) 603.314.0213 Student Name:____________________________________________ MCPHS ID:#___________________ Household Information Number of Household Members: List below the people in the parents’ household. Include:  Yourself and your parent(s) (including stepparent) even if you don’t live with your parents.  Your parents’ other children if your parents will provide more than half of the children’s support from July 1, 2014, through June 30, 2015, or if the other children would be required to provide parental information if they were completing a FAFSA for 2014–2015. Include children who meet either of these standards even if the children do not live with your parent(s).  Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will continue to provide more than half of their support through June 30, 2015. Number in College: Include below information about any household member, excluding the parents, who will be enrolled at least half time in a degree, diploma, or certificate program at an eligible postsecondary educational institution any time between July 1, 2014, and June 30, 2015. Include the name of the college. If more space is needed, provide a separate page with the student’s name and ID number at the top. Full Name Age Relationship College Self MCPHS University Parent N/A Will be Enrolled at Least Half Time (Yes or No) N/A Note: We may require additional documentation if we have reason to believe that the information regarding the household members enrolled in eligible postsecondary educational institutions is inaccurate. Certification I/we certify that all information reported on all sections of this form and any attachments hereto are true, complete, and accurate. Warning: If you purposely give false or misleading information, you may be fined, be sentenced to jail, or both. Parent 1 Signature Student’s Signature Date Parent 2 Signature Date ***Please return completed form to the Office of Student Financial Services*** Date