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2021-2022 International Student Financial Statement Child Care Assistance Program
UW Bothell - International Student Financial Statement
Student inclusion of text write-in signature near the end of this form authorizes Financial Aid to verify the information student provided.
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* Indicates required question
Email
*
Your email
Student Name (Last Name, First Name)
*
Your answer
UW Student ID#
*
Your answer
Home address (street address, city, state, zip code)
*
Your answer
Telephone number
*
Your answer
UW email address
*
Your answer
Date of Birth (Month/Day/Year)
*
MM
/
DD
/
YYYY
Are you a U.S Citizen or Permanent Resident?
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Yes
No
Other:
What is your student class level?
*
Graduate/Professional Student
Undergraduate
Other:
Student Marital Status and Household Size
What is your marital status as of today's date?
*
Single, Divorced, Widowed
Married/Re-married
Separated
Other:
Spouse's name (Last Name, First Name)
*
Your answer
Is your spouse a UW Student?
Yes
No
Other:
Clear selection
If yes, what is your spouse's UW ID#?
Your answer
What is the number of people in your (and your spouse's, if married) household? Count yourself, spouse (if married) and child(ren) living with you and supported by you.
Your answer
Of the number you listed in your household, how many will be attending college in 2021-2022?
Your answer
Income information
Please write in "not applicable" if an income question does not apply to your household in one of the categories below.
2020 Income earned from work (student)
*
Your answer
2020 Income earned from work (spouse)
*
Your answer
Total 2020 income reported on student and spouse's (if married) federal/national tax forms
*
Your answer
Total 2020 federal/national tax paid by you and your spouse (if married)
*
Your answer
Other student and spouse (if married) household income for 2020 not listed above (for example, money received or paid to you and/or your spouse (if married) not reported on this form).
*
Your answer
Student and spouse (if married) cash, savings, and checking account balance total
*
Your answer
Student and spouse (if married) current net worth of investments.
*
Your answer
Student and spouse (if married) current net worth of business.
Your answer
Student and spouse (if married) net worth of investment farm.
*
Your answer
Other Resource Information
List all scholarships, governmental benefits, or other financial support student will receive during the 2021-2022 academic year. Indicate the name of the resource and the amount of support.
Other Resource 1. Name of Source of Funding
*
Your answer
Other Resource 1. Amount of Monetary Support from Resource 1
*
Your answer
Other Resource 2. Name of Source of Funding
Your answer
Other Resource 2. Amount of Monetary Support from Resource 2
Your answer
Other Resource 3. Name of Source of Funding
Your answer
Other Resource 3. Amount of Monetary Support from Resource 3
Your answer
Student Certification and Signature
Student inclusion of text write-in signature.
By signing below, I certify the information provided on this form are true and complete to the best of my knowledge.
Student Signature (text write in first name and last name)
*
Your answer
Date
MM
/
DD
/
YYYY
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