GRANTED           YES (    )     NO (    )
TYPE   ____________________________
START_____________ END____________
DATE____________ INITIALS___________
 

FEDERAL PERKINS/DIRECT LOAN

INCOME AND EXPENSE SUMMARY

Supporting documentation is required
 
1. Monthly Income: $_________________
  Your wages (furnish copy of check stub) $_________________
  Spouse wages (furnish copy of check stub) $_________________
  Service allotments (furnish evidence) $_________________
  Publish Assistance or unemployment compensation (furnish evidence) $_________________
  Other income (furnish evidence) $_________________
 

      Total

 $_________________
 
2. Do you support, either fully or in part, anyone other than yourself? _________________
  If yes, list the name, address, age and relationship of each person you support:  
             
  Name   Address   Age Relationship
  ________________________   ___________________________   ___________ __________________
  ________________________       ___________________________       ___________ __________________
  ________________________   ___________________________   ___________ __________________
 
3. Monthly Expenses: (Please furnish documentation)  
     
  Housing $_________________   Medical $_________________ (after insurance)  
  Telephone $_______________   Electricity $________________   TOTAL $_________________
  Transportation: Bus, train, car, etc. (if you own car - year, make, model)    
  ________________________________________________________________________  
  Clothing/Laundry:         $_________________
  Food:         $_________________
  Maintenance/Repairs:         $_________________
  Other Expenses:         $_________________
 
4. List expenses paid on an installment basis: (INCLUDE ALL STUDENT LOANS)  
  Name of Creditor   Location   Original Amount of Debt   Amount of Payment (mo.) Balance Owed
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________       $_______________       $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
  ________________________   ______________________   $_______________   $_______________ $_______________
 

 
FEDERAL PERKINS/DIRECT INCOME AND EXPENSE SUMMARY
 
5. Name and address of Checking/Savings Institution:
  ______________________________________________________________________________________
  Savings Account Balance   Amount of Cash on Hand   Checking Account Balance  
  $__________________   $__________________   $__________________  
  Value of other personal property: (Trust funds, stocks, bonds, real estate) $___________________
 
6. Are you able to borrow funds from any relative or lending institution:  
  Yes_____________     No____________      If yes, in what amount? $____________________
     
7. Current Employer and Dates of Employment Address Monthly Income
  ____________________________________________ ________________________________ $__________________
   
________________________________		  
  Previous Employer and Dates of Employment    
  _____________________________________________ ________________________________ $__________________
   
________________________________		  
   
 

PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT YOU FEEL WILL BE HELPFUL IN RENDERING A DECISION.

I know that anyone who makes a false statement or false representation of material fact to avoid payment of an obligation due under the FEDERAL PERKINS/DIRECT LOAN PROGRAM may face serious consequences. I affirm that the above statements are true.
   
  Borrower's Signature Social Security # Date
   
   
  Mailing Address City State                                    Zip
       
       
  Phone Number