Knowledge that Transforms

The purpose of this form is to document your financial status. Your contribution to the cost of your individualized plan for employment (IPE) will be determined based on your income and funds from real and personal assets. This information will be used by the Division of Vocational Rehabilitation (DVR) to calculate your ability to financially contribute to the costs of your IPE. This form is to be completed by you and a DVR representative based on information provided by you, your parent, guardian, or other representative if applicable. Your income, assets, and liabilities will be calculated on the basis of either your family unit or you as an individual customer depending on your federal income tax filing status during the last tax year. A. Modified Adjusted Gross Income (Simplified Financial Statement) Complete if you have your most recent tax return: Complete if you do NOT have your most recent tax return: