Student Name UDID
(For any category in which you had no income or resource, please record “0”.)
2017 Student/Spouse Income/Resource Type Monthly Income/Resource Amount
Income from Work (gross amount) $
Business Income $
Unemployment Compensation $
Social Security Benefit $
Child Support Received $
Worker’s Compensation $
Disability Benefits $
Alimony $
Welfare, AFDC, TANF $
Housing Assistance $
Food Stamps (SNAP) $
Cash Assistance (from family and/or friends) $
In-Kind Support (bills paid on your behalf by someone else, but
$
Total Monthly Income/Resources
X 12 = Total Yearly Income/Resources
Explanation of Situation (REQUIRED)
Please explain your situation. Include as much detail as possible about how your family covered housing, utilities, and
other living expenses for calendar year 2017. An explanation is also required if few or no expenses were listed. If you used
savings, lines of credit, etc, to meet your expenses, attach 3 consecutive monthly statements from those accounts.
I certify that all information reported is complete and accurate to the best of my ability. I understand that any false
statement or misrepresentation may be cause for reduction and/or repayment of federal, state, or institutional financial
aid. I also agree to provide additional documentation for the information provided on this form, if requested by Student
Student Signature Date