Revised6‐27‐19
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Clarification of 2017 Income Sources –STUDENT
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Please Type or Print clearly in BLUE or BLACK ink
Student’s Information
______________________________________________________ ________________________________
Student’s Last Name Student’s First Name Student’s M.I. Student’s ID #
We have received your FAFSA for the 2019-2020 academic year. The income you reported for 2017 on your Federal application
for financial aid is extremely low and is below minimum levels necessary to support you and/or your family.
Please list the following amounts received in 2017 and how often you received the amount:
2017 AFDC/ADC $ per year month week
2017 Child Support $ per year month week
2017 Social Security $ per year month week
2017 General relief $ per year month week
2017 Food Stamps $ per year month week
2017 Section 8 housing supplement per year month week
2017 support received from other persons (count value for food, shelter, cash, medical, clothing, etc.) Amount of support
received $ per year month week
Name of person
Relationship
(If a parent is providing the majority of support, the student may be a dependent student)
List the value of 2017 bills paid by other people or groups (church, employer, etc.)
Amount of support received $
per
year
month
week
Name of person/group
Relationship
Any other 2017 income
Source of Income
per year month week
Estimate a typical month’s expenses during 2017 (expenses for food, housing, utilities, transportation, medical, etc.)
$ (per month)
Student Signature
Date
Office of Financial Aid
501 Varsity Road 1533 Hwy 19 South 300 Lakemont Drive
Griffin, GA 30223 Thomaston, GA 30286 McDonough, GA 30253
770-228-7368 p 706-646-6386 p 770-914-4411 p
770-229-3029 f 706-646-6063 f 770-229-3236 f
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signature
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Revised6‐27‐19
Declaration of No Income
Please complete the following if you have declared no taxable income.
I,
Name (Print clearly)
, did not work in 2017 and therefore had no
Income* because I was:
Incarcerated
Lived with parents/relative
Lived with other party,
Name of Party
Relationship to other party_
* You must provide documentation from the IRS dated on or after October 1, 2018 that indicates
2017 IRS income tax return was not filed with the IRS. You can request this document by completeing
an IRS form 4506-T and checking box 7. You will receive this form within 10 business days once the IRS
receives the request. If you have any questions, please stop by our office or call 770-228-7368.
Signature of person declaring no income
Date
Name of Student (if different from name above) Southern Crescent Student ID#
Please submit this worksheet to the Office of Financial Aid!
As set forth in full in the Student Handbook/Course Catalog, Southern Crescent Technical College is an Equal Opportunity Institution and does not discriminate on the basis of race, color,
national origin, sex, age or disability.
WARNING: Ifyoupurposelygivefalseor
misleadinginformation,youmaybefined,sent
toprison,orboth.
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signature
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