U.S.

Department of Education
Financial Disclosure Statement
To evaluate a hardship claim, ED compares the expenses you claim and support against averages spent
for those expenses by families of the same size and income as yours. ED considers proven expenses as
reasonable up to the amount of these averages. If you claim more for an expense than the average spent
by families like yours, you must provide persuasive explanation why the amount you claim is necessary.
These average amounts were determined by the IRS from different government studies. You can find the
average expense amount that the Department uses at this IRS website:
http://www.irs.gov/individuals/article/0,,id=96543,00.html then select “Administrative Wage Garnishment,”
and then click on “COLLECTION FINANCIAL STANDARDS.”

Provide complete information about your family income, expenses, and assets.
• Complete all items. Do not leave any item blank. If the answer is zero, write zero.
• Provide documentation. Expenses may not be considered if you do not provide documents
supporting the amounts claimed. You must submit proof of Childcare / Other Caregiver
expenses, in order to receive full credit for claimed caregiver cost. To obtain the form,
contact Customer Service at: 1-800-621-3115 or go to ED website at:
http://www.ed.gov/offices/OSFAP/DCS, select forms then Declaration of Caregiver Services.

• Provide documentation of all sources of income. You must submit two (2) most current pay
stubs for yourself, spouse, and all sources of income in your household. You may submit last
years W-2’s and 1040 Income Tax Filing as proof of household income. Failure to provide this
information may result in a denial of your claim of extreme financial hardship.

Income

Name: _____________________________ Social Security No.: _______________

Address: _____________________________
_____________________________ Phone: __________________________
_____________________________ County: _________________________

Current Employer: _____________________ Date Employed: __________________

Employer Phone: _____________________ Present Position: __________________

Gross Income: $___________ ‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly ______

Net Income: $___________ ‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly ______

***ENCLOSE A COPY OF YOUR TWO MOST RECENT PAY STUBS***

***ENCLOSE LAST YEARS W-2s AND 1040 INCOME TAX FILING***

Number of dependents: ______(including yourself) Marital status:‰ Married ‰ Single ‰ Divorced

Spouse name: __________________________ Spouse SSN: _____________________

Gross Income: $___________ ‰ Weekly ‰ Bi-Weekly ‰ Monthly ‰ Other _____

Net Income: $___________ ‰ Weekly ‰ Bi-Weekly ‰ Monthly ‰ Other _____

***ENCLOSE A COPY OF THE TWO MOST RECENT PAY STUBS***

***ENCLOSE LAST YEARS W-2s AND 1040 INCOME TAX FILING***
Other contributing resident(s): __________________________ SSN: _____________________

Gross Income: $___________ ‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly

Net Income: $___________ ‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly

***ENCLOSE A COPY OF THE TWO MOST RECENT PAY STUBS***

***ENCLOSE LAST YEARS W-2s AND 1040 INCOME TAX FILING***
Other Income
Child support: $___________‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly
Alimony: $___________‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly
Interest: $___________‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly
Public assistance: $___________‰ Weekly ‰ Bi-Weekly ‰ Bi-Monthly ‰ Monthly
Other: $___________ Describe: __________________________________

Please State and Explain Amounts Deducted from your pay stub

Life insurance $_________ _______ _____________________

Medical & Dental Insurance $_________ ____________________________
Retirement $_________ ____________________________
401K $_________ ____________________________
Garnishment $_________ ____________________________
Child Support $_________ ____________________________
Other (explain) $_________ ____________________________

Monthly Expenses

Shelter (SEND COPY OF MORTGAGE OR LEASE, INSURANCE, MAINTENANCE PAYMENTS)

Rent/Mortgage: $___________ Paid to whom: __________________________
2nd home mortgage: $___________ Paid to whom: __________________________
Home insurance: $___________ Paid to whom: __________________________
Maintenance: $___________ Paid to whom: __________________________
Other: $___________ Describe: ______________________________
Household Expenses
Food Expenses: $___ _______ (Monthly)
Housekeeping Supplies: $ _________ (Monthly)
Clothing & Cleaning: $__ ________ (Monthly)
Personal Care Services and Expenses: $__________ (Monthly)

Utilities (SEND COPIES OF BILLS)

Electric: $___________ Gas: $___________
Water/Sewer $___________Garbage pickup: $___________
Basic telephone: $___________Other: $___________
Describe: ___________________ ______________________________

Medical (SEND COPIES OF BILLS)

Insurance Premiums $___________/per month (only list premiums not deducted from paycheck)
Bill payments $___________/per month (only list payments not covered by insurance)-
Other: $___________/per month Describe: ______________________________
Transportation (SEND COPIES OF CAR PAYMENT AGREEMENT OR BILLS):

Number of Cars_________

1st Car payment: $___________/per month 2nd Car payment:$__________ /per month
Gas and oil: $___________/per month Public transportation:$___________/per month
Car insurance: $___________/per month Parking:$___________/per month
Maintenance $___________/per month Registration: $___________/per year
Other: $___________ Describe: ___________________________

Child Care (SEND COPIES OF BILLS, COURT ORDERS, CONTRACTS, Declaration of

Caregiver Services)
Child care: $___________/per month Number of children: _____
Child support: $___________/per month Number of children: _____
Other: $___________/per month Describe: ____ ______________________

Other Expenses: (Attach a list describing expense, monthly payment and enclose bills)
Other Insurance: $___________/per month
Describe: ______________________________________________

Based on this Statement, I think I can afford to pay $______________per month

I declare under penalties provided by 18 U.S.C. Section 1001 that the answers and statements contained
herein are to the best of my knowledge and belief true, correct, and complete.

Signature ____________________________________________ Date ___________

Warning: 18 U.S.C. 1001 provides that “whoever…knowingly and willfully falsifies, conceals, or covers up
by any trick, scheme, or device a material fact, or makes any materially false, fictitious, or fraudulent
statement or representation…shall be fined up to $10,000.00 or imprisoned up to five years, or both.”

Complete, sign, and return the requested information to: U.S. Department of Education
P. O. Box 617635
Chicago, Illinois 60661-7763
Telephone No: (312) 730-1477

Privacy Act Notice

This request is authorized under 31 U.S.C. 3711, 20 U.S.C. 1078-6, and 20 U.S.C. 1095a. You are not
required to provide this information. If you do not, we cannot determine your financial ability to repay
your student aid debt. The information you provide will be used to evaluate your ability to pay. It may
be disclosed to government agencies and their contractors, to employees, lenders, and others to enforce
this debt; to third parties in audit, research, or dispute about the management of this debt; and to parties
with a right to this information under the Freedom of Information Act or other federal law, or with your
consent. These uses are explained in the Federal Register of June 4, 1999, Vol. 64, p.30166, revised
Dec.27, 1999, Vol. 64, p. 72407. We will send a copy at your request.

This is an attempt to collect a debt and any information obtained will be used for that purpose.