INCS20 Rev. 3/18/19
Office of Financial Aid
2019-2020
LOW INCOME STATEMENT
Student Name: SCC ID#:
Please fill out the 2017 income statement below using annual/yearly amounts for each source listed, if it does not
apply, list zero ($0). When completed, this worksheet should demonstrate how you were able to support yourself and/
or your family in 2017. Please provide all 2017 income information. If you are a DEPENDENT student, you must
include parental information. (Please use blue or black ink only).
Sources of Income Please Circle all that apply below
or Spouse Income
(dependent
Earnings from all jobs (include cash-paying jobs)
$ $
Financial Aid received
$ $
Social Security / Social Security
Disability / Supplemental Security
$ $
CalWorks / TANF / CalFresh (SNAP)
$ $
Child Support received
$ $
Alimony / Palimony received
$ $
Unemployment / Workers
Compensation / Disability Compensation
$ $
Withdrawals from savings, retirement, and/or trust accounts
$ $
Cash received from family and/or friends
$ $
Bills (in your name) paid by someone else on your behalf
$ $
Non-educational Veteran Benefits
$ $
Other income not listed above (Source: )
$ $
If you had LOW income or NO income source for 2017, please explain how you were able to meet your needs for: rent, food,
utilities (electricity, water, telephone, etc.), clothing, and essentials. Attach additional pages if needed.
As certified by the signature(s) below, all information provided by myself or others is true and complete to the best of
my/our knowledge. I understand the SCC Financial Aid Office may request additional documentation to verify the
above information. If you purposely give false or misleading information on this worksheet, you will be reported to the
U.S. Department of Education. You may be fined, sentenced to jail, or both.
NOTE: If you are a dependent student, your parent(s) must also sign this form.
Student Signature: Date:
Parent Signature: Date: ____________________________
