Student Name:________________________________ Social Security Number:____________________

DVRS Counselor:__________________________________Office Phone Number: _________________

Part A. Expenses: (To be completed by DVRS using College Aid Commission Figures)

1. Tuition and fees $___________________

2. Standard Allowance $___________________

3. Room and Board $___________________

4. Attendant Costs $___________________

Total Expenses (Add lines A.1 through A.4) $__________________

1. Parent Contribution $___________________

2. Student Contribution $___________________

3. PELL Grant $___________________

4. Supplemental Educational Opportunity Grant (SEOG) $___________________

5. Job Training Partnership Act (JTPA) $___________________

6. Veteran’s Administration (VA) $___________________

7. Other Grants and Awards $___________________

Total Benefits (Add lines B.1 through B.7) $__________________

Signature of Financial Aid Personnel _______________________________________________________

Date of above figures_____________

Part C. Unmet Need [Total A (Expenses) minus Total B (Benefits)] $__________________

Part D. Amount of DVRS participation

(Not to exceed currently established limits) $__________________

Part E. DVRS participation in tools, equipment, class-required expenses

(Not to exceed the amount of Part C minus Part D) $__________________

I authorize ____________________________________________________(School) to release the information called for in Part B, above, to the Iowa Division of Vocational Rehabilitation Services to help determine the amount of their financial involvement in my training.

__________________________________________ _________________________________

Student Signature Date