(*) denotes required information.
* Student's Name:
* Name of Person Completing Form:
Complete this section if your parent(s) income in 2013 will be less than their income in 2012.
Estimated 2013 taxable earnings (including any income from work, investments, business/farm, severance pay)
Estimated 2013 non-taxable income (Social Security, Workman's Comp, Child Support)
Estimated 2013 Unemployment Compensation
Briefly explain the reasons for the change(s) in income:
If your parents were recently divorced or separated, but filed a joint 2012 tax return, please provide the following items:
All items are needed to make any adjustment.
Check here if this condition applies to you.
After submitting this online form, you will need to send the documents listed above to:
Financial Assistance Office
1501 W. Bradley Avenue
Peoria, IL 61625
You may also fax documents to (309) 677-2798. Please include your name and Social Security number on any documents you mail or fax.
You indicated that your family has incurred medical/dental expenses in excess of 10% of your adjusted gross income. Please forward the following:
Use this space to briefly explain any other circumstance you think should be considered:
We cannot process your worksheet without your verification below.
We certify all the information provided to be correct and accurate. We also understand that if the projected circumstances fail to materialize, any financial assistance received because of the conditions is subject to recision on this or subsequent academic years.
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