Delgado Community College-SSS-Income Verification Form

INCOME VERIFICATION FORM

Delgado Community CollegeStudent Support Services Program
Please list any income you and/or your family received in 2023, if you are stating that you do not file taxes or claiming zero income. Please include all income from work, disability, unemployment, social security, child support, and/or income received from relatives/friends.
Name*

First NameLast Name
Email*
example@example.com
LOLA#*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Household Size is based on the number of people who received more than half financial support. Please indicate your household size (Include yourself)*

Total Income for Jan. 2022-Dec. 2022

	Student/Spouse ($)	Parent ($)
Income from Work (gross amount)
Social Security Income
Unemployment Benefits
Child Support
Public Assistance
Food Stamps
Other (specify_________________________)
Other (specify_________________________)
Other (specify_________________________)

I certify that the information provided on this form is true and correct to the best of my knowledge. I will provide documentation to support the information provided on this form. I understand that failure to provide the requested information will result in denial of my application for the Student Support Services Program. For dependent students, the student and at least one parent must sign below.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

INCOME VERIFICATION FORM