If you answered “No” to questions 1 – 4 and “Yes” to question 5 or 6, you must provide income and household information
about your PARENT(S) and answer questions for a DEPENDENT student in Section B.
1. DEPENDENT STUDENT: How many persons are in your parent(s) household? (Include yourself, your parent(s), and
anyone who lives with your parent(s) and received more than half of their support from your parents, now and through
June 30, 2017.)
2. INDEPENDENT STUDENT: How many persons are in your household? (Include yourself, your spouse, and anyone
who lives with you and receives more than half their support from you, now and through June 30, 2017.)
For questions 3 and 4, please convert the income into American dollars.
DEPENDENT STUDENT: INDEPENDENT STUDENT
PARENT(S) INCOME STUDENT (AND SPOUSE’S INCOME
3. 2017 Income Information
a. Adjusted Gross Income $ $
(If 2017 U.S. Income Tax Return
was filed, enter the amount from
Form 1040, line 37; 1040A,
Line 21; 1040EZ, line 4 or
Telefile, line I). If not U.S. income,
report all income earned from work
b. All other income $ $
(Include ALL money received in 2017
that is not included in line (a) above.
Be sure to include all untaxed income.)
4. Total Income for 2017 $ $
(Sum of a + b)
I hereby swear and affirm, under penalty of perjury, that all information on this form is true and complete to the best of my
knowledge. If asked by an authorized official, I agree to give proof in support of the information provided on this form. I
also realize that any false statement or failure to give proof when asked may be cause for the denial, reduction,
withdrawal, and/or repayment of my waiver.
Applicant’s Signature Date Parent Signature (Dependent Students Only) Date
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For Office Use Only
Meets California College Promise Grant income standards: Yes No
Signature, FAO Date