Low Income Document Form

Parent Name*

First Last

Faulkner Student ID#*

Student Name*

First Last

You reported on your Free Application for Federal Financial Aid an unusually low amount of adjusted gross income, income earned from work, or income from other sources. Please answer the questions below by checking the blank next to the answer that most closely describes your situation for the calendar year:

Calendar Year for described situation*

Include a letter describing additional circumstances.

Housing*

Paid rent or mortgage payment for a house or apartment. (specify below)
Lived with parent(s).
Lived in government subsidized housing.

Monthly Amount Spent on Housing*

Utilities*

Included in rent.
Paid by friend or relative.
Paid by self. (specify below)

Monthly Amount Spent on Utilities*

Transportation*

Owned a vehicle. (specify below)
Used a friend’s or relative’s vehicle.

Monthly Amount Spent on Transportation*

Food*

Paid by self. (specify below)
Assisted by food stamps.
Provided by friend or relative.

Monthly Amount Spent on Food*

Medical Expenses*

Covered by parent’s insurance.
Paid bills myself. (specify below)
Medicaid

Monthly Amount Spent on Medical Expenses*

Child Care*

Friend or relative keeps children free of charge.
Not applicable.
Paid by self (explain)

Explain*

I received financial aid from: (Check all that apply)

Student Loans (specify below)
Pell Grant (specify below)
State Grant (specify below)
Scholarship (specify below)
Other (specify below)

Amount from Student Loans*

Amount from Pell Grant*

Amount from State Grant*

Amount from Scholarships*

Amount from "Other"*

If "other" is selected, explain:*

Signature*

I agree that the information provided is accurate, and that I am person whose name appears on this form.

Introduction

Low Income Document Form