Office of Student Financial Aid
Low Income Statement for Student 2020-2021
TO BE COMPLETED BY THE STUDENT
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Student Last Name Student First Name MI Last 6 digits only
The 2018 income reported on your 20202021 FAFSA appears insufficient to support the people in your
household, no income was reported on the FAFSA, or some or all the income section on the FAFSA was left
blank. Complete this form to clarify how you supported your household during 2018. Include all monthly
costs from January 1, 2018 through December 31, 2018.
WRITE “0” OR N/A if not applicable. DO NOT LEAVE ANY SECTION BLANK.
Indicate (paid in full) under “who paid for expenses” column if your home is paid for.
Indicate (included in rent) under “who paid for expenses” column if utilities are included.
Documentation may be requested.
EXPENSES PER MONTH FOR 2018
Item
Amount Paid
Per Month
by Someone
Else
Who Paid for Expenses? (Myself,
HUD, Friend, Significant Other,
Grandparent, etc.)
Amount You
Paid Per
Month
Rent/Mortgage
$
$
Utilities (Electric, Gas, & Water)
$
$
Food (Indicate “0” Only If Received Food Stamps)
$
$
Telephone/Cable
$
$
Medical/Dental/Vision Insurance
$
$
Child Care Expenses Paid
$
$
Car Payment/Car Insurance/Transportation
$
$
Clothing
$
$
Other (Identify Sources)
$
$
INCOME PER MONTH FOR 2018
Source of Income
Amount Received Per Month
Wages from employment (Employer’s Name or Business Income if self-
employed)
$
Child Support/Alimony Received (Please circle which applies)
$
AFDC Benefits {Specify type(s) and amount(s)}
$
Social Security/Social Security Disability (Please circle which applies)
$
Unemployment/Worker’s Compensation (Please circle which applies)
$
Monetary gifts from family/friends
$
Military or clerical housing, clothing, food, or cash (list cash value)
$
Any other untaxed income (Please indicate source)
$
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Student Last Name Student First Name MI Last 6 digits only
Did you receive Financial Aid refund(s) in 2018 to finance your expenses? Yes No
If “Yes”, please indicated the amount: $ .
Please use this space provided to include any additional information
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Certification Read carefully before you sign.
I/we certify that federal law does not require me/we to file a 2018 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. I understand that if I am found to have knowingly or intentionally
given false or fraudulent statements and/or documentation, my eligibility for Federal and State student aid may be jeopardized and I may be reported to the U.S.
Department of Education for possible investigation by the Office of the Inspector General.
Student Signature Date
PLEASE RETURN TO:
North Carolina Agricultural and Technical State University
Office of Student Financial Aid
1601 E Market Street
Greensboro, NC 27411
Fax: 336-334-7954 Telephone: 336-334-7973
12 x Income = $_______ Minus 12 x Expenses = $_______ = Total $_______
(If Total Income Greater Than Expenses Untaxed Income=0)
Counselor Signature: __________________________________ Date: ___________________
LOINC 20/21
REVISED: 11/19
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