MASS Program

Financial Disclosure Form



 

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Last Name                                                 First                                             MI                                             SS#

______________________________________________________________________________________

Street Address (Permanent)

______________________________________________________________________________________

City                                                                                                     State                                     Zip Code

___(______)____________________________________________________________________________

Phone                                                                                                   Email

______________________________________________________________________________________

University

Directions: To be completed by Financial Aid officer if applicable.

Do you plan to apply for any type of financial student aid for the fall 2002 semester?

________ Yes _______ No

If the answer is "yes", please visit this web site to apply.


Please itemize each of the following costs incurred at home university per semester and Financial Assistance student receives towards each.
Please attach a copy of student spring 2002 university billing statement.

TUITION
 
2002 Semester Tuition Rate $
Financial Assistance you receive towards tuition (per semester)
Name of Scholarship 
1. $
2. $
3. $
Name of Grant
1. $
2. $
3. $
Other
1. $
2. $
3. $

ROOM AND BOARD
 
2002 Semester Room cost  $
Financial Assistance you receive towards room (per semester) $
2002 Semester Meal Cost $
Financial Assistance you receive towards meals (per semester): $
You live at home and do not incur room and board expenses ____ Yes

FEES
 
Total of all mandatory fees $
Financial Assistance you receive towards fees $
Name of Mandatory Fees
1. $
2. $
3. $
4. $
5. $

OTHER EXPENSES
 
1. $
2. $
3. $

Please complete Financial Aid Officer information, if applicable:

______________________________________________________________________________________

Last Name                                                                         First                                                     MI

______________________________________________________________________________________

Street Address

______________________________________________________________________________________

City                                                                                 State                                         Zip Code

___(______)____________________________________________________________________________

Phone                                                                                                               Email

________________________________________________________________________

Signature                                                                                                                             Date
 
 
 
 

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Student Signature                                                                                                                 Date