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LowincomedocumentStudentforfillable

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Country of origin: US
File type: PDF

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Financial Aid Office
(708) 709-3735
Fax: (708) 709-3716
M:\StuServ\FAVAoffice\2015-16 Forms\LowincomedocumentStudentforfillable.docx
2015-16 Independent Low Income Document
To be completed by Student
Student’s Name ID#/SS#
The Office of Financial Aid is in the process of reviewing your for financial aid and has found that additional
information is required in order to determine his/her eligibility. On the Free Application for Federal Student Aid
(FAFSA) you reported one of the following
No income reported in 2014;
Some or all of the income section on the FAFSA was left blank; or
You reported unusually low income that appears to be inconsistent with the number of family
members supported.
Using the chart below, list the 2014 yearly living expenses for your household. You will need to indicate
your yearly amount due, how much was paid, any amount paid by someone else, and who provided
assistance. If the chart is left blank or lists all “$0’s” this form will be returned for completion and the
process of your financial aid will be delayed. Please carefully review the examples below to see how to
properly report your information.
2013 Household Living Expenses
Yearly
amount of
expense
Amount paid
by you
Amount paid
by agency/other person
Who provided the
assistance?
EXAMPLE – Housing
$500
$250
$250
HUD
EXAMPLE – Insurance
$100
$0
$100
Parents
Housing (rent or mortgage)
Child care
Utilities
(heat, electricity, phone, etc.)
Insurance
(health, life, car, renter’s, home, etc.)
Medical/dental (Medicaid, enter $0)
Transportation
(bus, car, gas, subway, etc.)
Food
Clothing/Other personal expenses
Student Resources: Did you receive free housing, utilities, transportation, or other living expenses from
a friend, relative, or someone with whom you have a relationship? Yes No
If yes, provide the name and relationship of any other person(s) who paid/assisted with any of the
above expenses:
Name______________________________________Relationship________________________________
Name______________________________________Relationship________________________________
Turn over to complete
Use the chart below, list the 2014 yearly income for your household. You will need to indicate the
source and the yearly amount received in 2014. Include documentation of wages (2014 W2 or tax
transcript), TANF statements, Social Security Benefits, workman’s compensation, insurance settlements;
any other untaxed income or benefits such as military or clerical housing, clothing, money, gifts, loans,
food, or the cash value of any benefits (any money paid to someone else on your behalf), etc.
For example, if a friend or relative pays your rent, electric, food, cable, etc., you must report the amount
as Monetary gifts from friends/family.
DO NOT LEAVE ANY SECTION BLANK
For items that do not apply, write “0” in the field.
2014 YEARLY INCOME (***Please attach documentation for all sources of income***)
Source
Yearly
Amount Received
for 2014
Wages/Income earned from work (Attach 2014 W2)
$
Child Support and/or Alimony Received (attach Court Document/Proof of Payment Received)
$
TANF/Welfare Benefits (Attach 2014/2015 Benefit Statements)
$
SSI and/or SSA (attach 2014 yearly statements)
$
Other disability payments (specify source and attach documentation)
$
Unemployment Compensation (attach 2014 Benefit Statement)
$
Pension and/or Retirement Benefits (attach 2014 Benefit Statement)
$
Veterans Benefits or Workman’s Compensation (attach 2014 Benefit Statement)
$
Monetary Gifts from family and/or friends
$
All other untaxed income (specify source and attach documentation)
$
Statement
Please explain how you and your family lived on little or no resources in 2014. Incomplete statements
will be returned to the student.
Certification – Read carefully before you sign.
I certify that federal law does not require me/we to file a 2014 U.S. federal income tax return and that one will not be filed. I
hereby certify that all information contained in this document, including the documentation is true and complete.
Student’s Signature _______________________________________ Date _____________________
Spouse’s Signature ________________________________________ Date _____________________
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LowincomedocumentStudentforfillable

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Completed 18 November 2019

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