DANVILLE COMMUNITY COLLEGE’S UPWAR BOUND PROGRAM
CONFIDENTIAL FINANCIAL INFORMATION
DATE:
STUDENT NAME
Indicate Person Reporting Information:  Mother
relationship
)
 Father
 Both
 Guardian (if so,
 Check here if parent did not/will not file income tax return (must provide proof of income for
reporting year. Skip to Question 2 and complete Questions 2, 3, 4, & 5 and sign/date form)
If Parent(s)/Guardian(s) will file/filed Income Tax Return, complete all of the following:
1. Adjusted Gross Income (AGI) for reporting income tax year .... $
a. Number of dependents claimed for tax year
b. Number of household members for the reporting tax year
2. If parent reporting does not require filing of an income tax return, please indicate the
approximate amount of household income for reporting year $
a. Number of family members supported by this income
3. Does your family live in federally subsidized housing?  Yes  No
4. Are any household members receiving any of the following benefits (check all that apply):
 *Welfare Benefits (such as TANF)  *Social Security Benefits (SSI)
 *Child Support
 Free/Reduced School Lunch
 WIC
 Other:
*indicates subject to verification
5. In order for your son/daughter to meet program eligibility requirements, we must obtain
copy(s) of your last year’s financial statements such as Income Tax Return indicating
Family Household Size, Adjusted Gross Income (AGI), copies of Welfare Benefits or other
income received for reporting year (such as TANF, SSI, Child Support, Unemployment, etc) .
The information will be kept confidential; however, we are required by federal laws and
regulations to obtain and verify student’s eligibility status.
Please sign indicating you have read the above information, completed, and agree to submit
required documentations to verify student’s income eligibility for program enrollment.
I hereby affirm that the information provided on this form is true and complete. I further
understand that the information is subject to verification.
Signature:
Date:
Revised 2-Oct-08
1