Section 1. Student Information

1 2500 N. River Road | Manchester, NH 03106 | Phone: | Fax: The income you have reported on your Free Application for Federal Student Aid (FAFSA) is unusually low. We are required to request additional documentation about your household finances so that we may understand your expenses and how the household is meeting its financial obligations. Please complete this worksheet printing clearly in ink. Section 1. Student Information Full Name Student ID Address City State ZIP Code Phone Number (including area code) Date of Birth Email Address Section 2.

2 Household Income/Resource Information List in the chart below the income and resources with which you and if applicable, your spouse supported the household in 2015. Please ensure that you list any money received from ANY source. Do NOT leave any Section blank; indicate N/A or 0 if an item or box does not apply to you. 2015 Source of Income Name of Employer or Payer Person Who Received the Income 2015 Monthly Amount Received Student s Employment 1. Student $ per month 2. Student $ per month Spouse s Employment 1. Spouse $ per month 2. Spouse $ per month Child Support Received Student or Spouse (circle one) $ per month Alimony Student or Spouse (circle one) $ per month Unemployment Benefits Student or Spouse (circle one) $ per month Cash or Gifts Student or Spouse (circle one) $ per month Money received, or paid on your behalf ( , bills), not reported elsewhere on this form.

3 Student or Spouse (circle one) $ per month Section 3. Government Benefits At any time during 2015 or 2016, did you or your spouse receive benefits from any of the federal programs listed below? Answering these questions will NOT reduce eligibility for Student aid or these programs. Source of Income Person Who Received the Income 2015 2016 Social Security Benefits Student or Spouse (circle one) Yes No (circle one) Yes No (circle one) Social Security Disability Insurance Student or Spouse (circle one) Yes No (circle one) Yes No (circle one) Section 8 Assistance Student or Spouse (circle one) Yes No (circle one) Yes No (circle one) Supplemental Nutrition Assistance Program (SNAP) Student or Spouse (circle one) Yes No (circle one) Yes No (circle one) Other Government Benefits (specify below)

4 Student or Spouse (circle one) Yes No (circle one) Yes No (circle one) 2500 N. River Road | Manchester, NH 03106 | Phone: | Fax: Section 4. 2015 Monthly Household Expense Information Please review the following examples to help determine your household expenses. Example A: If your 2015 rent expense was $400/month and you paid for it on your own, your rent expense is $400/month and you would circle No to indicate another person did not pay the expense on your behalf. Example B: If a friend/relative was allowing you to live with them free of charge, your rent expense is 0 and you would explain the situation next to the asterisk (*).

5 In this case, you would circle No to indicate another person was not paying the expense on your behalf. Example C: If your rent expense was $400 per month and a friend/relative was paying your bill, then you would write $400/month and circle yes to indicate someone else paid the bill on your behalf. Rent/Mortgage* $ /month Did another person pay this expense on your behalf? Yes No (circle one) *If 0 or N/A, you must explain here: Utilities* $ /month Food/Groceries* $ /month Health/Medical* $ /month ( insurance, prescriptions, etc.)

6 Did another person pay this expense on your behalf? Yes No (circle one) *If 0 or N/A, you must explain here: Did another person pay for this expense on your behalf? Yes No (circle one) Did you pay using the SNAP benefit? Yes No (circle one) *If 0 or N/A and you do not use SNAP, you must explain here: Did another person pay for this expense on your behalf? Yes No (circle one) Is your health insurance provided by Medicare/Medicaid? Yes No (circle one) *If 0 or N/A and you do not use Medicare/Medicaid, you must explain here: If the income listed in Section 2 does not exceed the expenses shown in Section 4, please include any additional Information relevant to your household income and/or expenses on the lines provided below: 2500 N.

7 River Road | Manchester, NH 03106 | Phone: | Fax: Section 5. Signatures and Certification I certify that the Information submitted is true and correct to the best of my knowledge and belief. If asked by an authorized official, I agree to provide additional proof of the Information provided on this form. I understand that purposely providing false or misleading Information on this form may result in reduction or repayment of aid, fines, and/or imprisonment in this and/or future years. Student Signature Date(required) Please note: electronic signatures will not be accepted.

8 Spouse Signature (optional) Date