FA-25 / 18-19 Page 1 of 1
2018-2019 Independent
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 you 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 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 your behalf
(e.g. bills) includes:
money for bills
housing, food, clothing
car payments or expenses
medical and dental care
college costs
For example, if a relative pays your
housing and tuition fees, you must report
the amounts as paid on your behalf.
Do not include amounts for in-kind
support (when you are not obligated to
pay an amount). For instance, if you live
with a parent and do not pay rent, you do
not need to report an amount as money
received for rent.
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 your behalf by parents* ...............
Money received, or paid on your behalf by others* .................
2016 Total Income (Yearly Amount)
Explain special circumstances (if any) concerning your financial situation. If you 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 must sign and date below. If married, the spouse's signature is optional. 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’s Signature (electronic signatures not accepted)
Spouse’s Signature (electronic signatures not accepted)
