Maryland Higher Education Commission - …



Guaranteed Access Grant

Low Income Form

Academic Year 2017-2018

A review of your financial aid application indicates that your total household income from all sources appears to be low or zero during 2015. You must indicate how you and your family were supported by specifying how living expenses were covered. Please complete ALL of the information requested on this form and return the document to the Office of Student Financial Assistance. We cannot proceed with the verification process for the Guaranteed Access Grant until we have received and reviewed this information.

SECTION A –Student’s Personal Information:

Social Security Number: ________________________

Last name: First name: MI:

Did you and your parents live with a relative or someone else who provided you with free or reduced room and board in 2015? Y N

Are you still receiving free or reduced room and board? Y N

Name and relationship of the person who provided the free or reduced room and board:

Name: Relationship: ______________________________

SECTION B –Income Information:

|Parent/Student INCOME |AVERAGE AMOUNT PER MONTH JAN. 2015-DEC. 2015 |

| Unemployment Benefits |$ |

| Social Security Benefits (including disability) |$ |

| SSI |Yes/No |

|Food Stamps |Yes/No |

|TANF (welfare) |Yes/No |

|Employer Disability |$ |

|Money received on your behalf from your parents and/or others |$ |

| Total monthly income |$ |

| | |

| | |

SECTION C –Additional Comments: If no income is listed in Section B, please provide an explanation as to how you and your parent (if dependent) were supported.

BY SIGNING THIS FORM, I CERTIFY THAT ALL THE INFORMATION REPORTED TO QUALIFY FOR THE GUARANTEED ACCESS GRANT IS TRUE AND ACCURATE. I UNDERSTAND THAT IF THIS FORM IS INCOMPLETE, MY FINANCIAL AID MAY BE DELAYED. IF ASKED BY AN AUTHORIZED OFFICIAL OF THE OFFICE OF STUDENT FINANCIAL ASSISTANCE, I AGREE TO PROVIDE PROOF OF THE INFORMATION THAT I HAVE GIVEN ON THIS FORM.

Student Signature: Date:

Parent Signature: Date:

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Maryland Higher Education Commission

Office of Student Financial Assistance

6 N. Liberty Street, Ground Suite

Baltimore, MD 21201

(410) 767-3300; (800) 974-0203

TTY for the Deaf - (800) 735-2258

mhec.state.md.us

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