FA-25 / 18-19 Page 1 of 1
2018-2019 Dependent
Income Statement
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
The income your parent(s) reported on the Free Application for Federal Student Aid (FAFSA) or Dream Act Application appears to be insufficient to
meet basic living expenses (housing, food, clothing, etc.). For clarification purposes, we need to obtain information regarding your and your parent(s)
additional income sources as of the date the FAFSA or Dream Act Application was filed.
Do not leave a question blank, indicate "0" if the amount equals zero.
Temporary Assistance for Needy Families (TANF) .................
Please complete all sections.
* Money received, or paid on student's
behalf (e.g. payment of student's bills)
and not reported elsewhere on this form.
If someone is paying rent, utility bills, etc.
for the student or gives cash, gift cards,
etc., include the amount of that person's
contributions unless the person is the
student's parent whose information is
reported on the student's 2018-2019
FAFSA. Amounts paid on the student's
behalf also includes any distributions to
the student beneficiary from a 529 plan
that is owned by someone other than the
student or parent(s) (such as
grandparents, aunts, and uncles).
Supplemental Nutrition Assistance Program (SNAP) ..............
CalWORKS or other Welfare Benefits .......................................
Social Security Benefits ...................................................................
Unemployment Benefits .................................................................
Spousal Support Received (e.g. alimony) ....................................
Child Support Received ..................................................................
Investment (Interest & Dividends) Income ................................
Retirement/Pension Income ..........................................................
Veterans Benefits .............................................................................
Workman's Compensation ............................................................
Disability Benefits .............................................................................
Other Income ....................................................................................
Financial Aid (refunded amount) ..................................................
Money received, or paid on student’s behalf (e.g., bills)* .......
2016 Total Income (Yearly Amount)
Explain special circumstances (if any) concerning your financial situation. If you and your parent listed zero total income, you must explain how you met
your everyday living expenses such as food, rent and clothing.
Certification and Signature
The student and one parent must sign and date below. Each person signing this worksheet certifies that all of the information reported on this form is
true and accurate to the best of their knowledge. Further, each person gives permission to an authorized representative of the Financial Aid &
Scholarships Office to verify any of the above information.
WARNING:
If you purposely give false or
misleading information on this
form, you may be fined, sentenced
to jail, or both.
Student Signature (electronic signatures not accepted)
Parent Signature (electronic signatures not accepted)
