Financial Aid Office
(708) 709-3735
Fax: (708) 709-3716
m:\stuserv\favaoffice\2016-17 forms\lowincomedocumentstudent.docx
2016-17 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 request for financial aid and has found that additional
information is required in order to determine your eligibility. On the Free Application for Federal Student Aid (FAFSA) you
reported one of the following
No income reported in 2015;
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.
In the section below, list the 2015 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 this
section 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.
1. Mortgage and taxes or rent payment per month: Amount: $_____ x 12 = yearly amount: $_________
Who paid? student/spouse bill in student/spouse name but someone else gives money to pay
allowed to live in someone else’s residence for free
agency name:_________________________________________
2. Utilities (electric, heat, etc.): per month: Amount: $_____ x 12 = yearly amount: $_________
Who paid? student/spouse bill in student/spouse name but someone else gives money to pay
allowed to live in someone else’s residence for free
agency name:_________________________________________
3. Food: per month: Amount: $_____ x 12 = yearly amount: $_________
Who paid? student/spouse bill in student/spouse name but someone else gives money to pay
allowed to live in someone else’s residence and eat their food
agency name:_________________________________________
4. Transportation (gas, train, bus, etc.): per month: Amount: $_____ x 12 = yearly amount: $_________
Who paid? student/spouse bill in student/spouse name but someone else gives money to pay
allowed to use someone else’s vehicle
agency name:_________________________________________
5. Medical and dental costs: per month: Amount: $_____ x 12 = yearly amount: $_________
Who paid? student/spouse bill in student/spouse name but someone else gives money to pay
given free services from_________________________________
agency name:_________________________________________
6. Clothing/Other personal expenses: per month: Amount: $_____ x 12 = yearly amount: $_________
Who paid? student/spouse bill in student/spouse name but someone else gives money to pay
agency name:_________________________________________
Turn over to complete
Provide the name and relationship of any other person(s) who paid/assisted with any of the listed expenses:
Name______________________________________Relationship________________________________
Name______________________________________Relationship________________________________
Use the chart below, list the 2015 yearly income for your household. You will need to indicate the source and
the yearly amount received in 2015. Include documentation of wages (2015 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.
2015 YEARLY INCOME (***Please attach documentation for all sources of income***)
Source
Yearly
Amount Received
for 2015
Wages/Income earned from work (Attach 2015 W2)
$
Child Support and/or Alimony Received (attach Court Document/Proof of Payment Received)
$
TANF/Welfare Benefits (Attach 2015/2016 Benefit Statements)
$
SSI and/or SSA (attach 2015 yearly statements)
$
Other disability payments (specify source and attach documentation)
$
Unemployment Compensation (attach 2015 Benefit Statement)
$
Pension and/or Retirement Benefits (attach 2015 Benefit Statement)
$
Veterans Benefits or Workman’s Compensation (attach 2015 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 2015. 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 2015 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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