Haskell Indian Nations University Phone: (785) 749‐8468
Financial Aid Office Fax: (785) 832‐6617
155 Indian Avenue, Box 5027 Email: faoffice@haskell.edu
Lawrence, KS 66046
The income reported on your Free Application for Federal Student Aid (FAFSA) is below $12,000 for the student and/or parent. Please
complete the income information and a justification below indicating how your living expenses were met during the 2018 calendar year.
2020‐2021 Low Income Verification: Dependent
Source of Money Received from
January 2018 ‐ December 2018
Parent Annual Amount
Jan. 2018 ‐ Dec. 2018
Student Annual Amount
Jan. 2018 ‐ Dec. 2018
Unemployment $ $
Child Support Received $ $
Vocational Rehabilitation $ $
Social Security Benefits $ $
Aid to Families with Dependent Children (AFDC/ADC) $ $
Earned Income Credit $ $
Housing Allowance $ $
Other: Support Received including Pell and Scholarships $ $
$ $
With income below $12,000, it is mandatory to complete this section. In this section, you will need to justify how you sustained on the income listed. If
you lived with someone who helped support you, please explain. If your parent’s income was not sufficient to pay rent/mortgage, food, utilities, and other
expenses, explain how their expenses were met:
PLEASE SIGN BELOW
By signing this form, I certify that all of the information reported on this worksheet is complete and correct to the best of my knowledge. I also
understand if I purposefully give false or misleading information on this worksheet, I am violating federal statute and could face penalty.
This form must be completed and signed by a parent if the student is dependent.
Student’s Signature Date
Print Student Name Date
Parent’s Signature Date
1 | P a g e 2 0 20‐ 2 0 2 1 L o w I n c o m e V e r i f i c a t i o n
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