Last Name First Name Middle Initial
___________________________________________________ ( )
Current Address Phone Number (Daytime)
City State Zip
( ) __________________
Social Security Number Student ID # E-mail Address
To request 2018 income to be used to determine your financial aid eligibility, complete Section A, B, and C,
attach documentation, sign and return to the Financial Aid office. Only circumstances that are beyond a
student/spouse/parent(s) control will be taken into consideration.
If you/your spouse’s/and/or your parent(s) income will be less in 2018 than 2017 for any reasons listed below,
check the appropriate reason in Section A, complete Section B, and explain your situation in Section C.
SECTION A:
Unemployment or change in employment (e.g. termination/layoff letter from employer, unemployment
statement, dislocated worker form).
Death of student’s parent or spouse (e.g. copy of death certificate, obituary, eulogy).
Disability of student, parent or spouse (e.g. medical document, accident report).
Other (submit appropriate documentation).
Loss of one-time income (e.g. military separation, pension or retirement, inheritance, court settlement)
Identify the source and amount of income and how the funds are spent or invested in Section C.
Provide your/your spouse’s/and/or parent(s) expected income and resources for the period January 2018
through December 2018. Documentation (W-2s, 1099s, tax returns, etc.) must be attached.
SECTION B: You (SSpouse tep) Father (Step) Mother
Wages, salaries, tips (income from work) __________ __________ __________ __________
Unemployment compensation __________ __________ __________ __________
Other taxable income Specify __________ __________ __________ __________ __________
AFDC/ADC/TANF __________ __________ __________ __________
Social Security benefits __________ __________ __________ __________
Child Support (Received) __________ __________ __________ __________
Child Support (Paid) To whom __________ __________ __________ __________ __________
Alimony __________ __________ __________ __________
Other untaxed income Specify __________ __________ __________ __________ __________
There must be a number on all lines, even if they are 0’s
