CLARIFICATION FORM - STUDENT STATEMENT OF LOW INCOME

Student's Name: Student ID/SSN:

You have reported unusually low income for the base tax year.  You must provide additional information about your income and expenses in 2013 to complete your financial aid processing.   

NOTE: If you indicated N/A for all the line items in Section II, you MUST provide a statement as to how you supported yourself in 2013. 

Section I (Housing)

1.  With whom did you live with in 2013?  Family Roommate/Significant/Other By Yourself

2.  In 2013, did your name appear on the Mortgage or Lease Agreement? Yes No

Section II:  Student Statement of Income (questions that don’t apply enter N/A for not applicable)
  1. 2013 EXPENSES: Indicate below who covered your yearly expenses for 2013.  Provide the name(s) and relationship(s) of who paid the expense or provided the item for you.  If you paid the cost, enter “Self”.  
Expense Who Paid/Provided

Utilities
Food
Clothing
Car Payment
Telephone/Cellular
Credit Card Payments
Auto Insurance

  1. 2013 Income: Identify the source of your yearly income for the year 2013.  
Type of Income/ISIR Question Who Paid/Provided

Wages from Work (FAFSA Q#38 and/or 39
Social Security Benefits (not reported on ISIR)
Child Support (FAFSA Q#44C)
*Cash Support (FAFSA Q#44J)
Other (Disability, Military) (FAFSA Q#. 44H & 44I)
*Cash support includes money, gifts, and loans, plus housing, food, clothing, car payments or expenses, medical and dental care, college costs and any money paid to someone else on your/spouse’s behalf.

I was married, supported by my spouse, and now I am separated, divorced or widowed.  I had income of $ for 2013 (do not include spouse’s income).  (If no income, enter 0).  This amount must be reported on the FAFSA as income earned from work or as untaxed income.   

Please describe any special circumstances regarding your source(s) of income for 2013 in the space provided.

I hereby certify that all information above is true and complete. I have not knowingly or intentionally provided any false statements or fraudulent documentation. I understand that if I am found to have knowingly or intentionally given false or fraudulent statements and/or documentation, eligibility for aid can be jeopardized.

By my signature I attest to having answered the following questions truthfully.


Name/Electronic Signature By typing your name you have created an electronic signature as legally binding as your handwritten signature.