Office of Scholarships and Financial Aid 2019-2020 Low ...

UHD ID: __________________ Student's First Name: __________________________ Last Name: _________________________

Office of Scholarships and Financial Aid 2019-2020 Low Income Statement

The income that you reported on your financial aid application for 2017 appears to be unusually low. As part of the

verification process, you must confirm the details of the information you reported. This worksheet is designed to show

how you and/or your family received monetary support in 2017. Also, if someone helped provide support to you/your

family in 2017, please have them complete the Student/Family Member Support section of this form.

Step 1: Expenses and Income

2017 Expense Type

Rent/Mortgage Utilities Car Payment/Ins. Car Maintenance/Gas Credit Card Payments Phone, Internet & Cable Clothing

Student/ Spouse Amount of 2017 Expenses Paid out of Pocket

Food

Entertainment

Child Support/Alimony Paid

Child Care

Other: Total 2017 Expenses

Parent (Dependent student) Amount of 2017 Expenses Paid out of Pocket

2017 Income Type

Student/Spouse Amount of 2017 Income/Earnings

Parent (Dependent Student) Amount of 2017 Income/Earnings

Earnings from ALL Jobs Unemployment Compensation Withdrawals from Savings Social Security/Disability Welfare, AFDC, TANF Child Support Received Alimony

Total Financial Aid REFUND received in 2017 Cash received from family and/or friends *Bills paid by someone else on your behalf *Please explain any other support below. You may use this space to describe your current living situation. Other:

Total 2017 Income

Please continue next page

Office Use Only Date:_________________________ Received By:_____________________ Fwd To: ________________________CHECKLIST: FD0LIS

UHD ID: __________________ Student's First Name: __________________________ Last Name: _________________________

Step 2: *List bills being paid, by whom, and provide examples of support (include food, shelter, clothing, non-cash gifts, etc.) Be sure to list the total dollar value of support received in 20147 (use reverse side if more space is needed). Please have this individual to complete Step 3 Student/Family Member Support. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Step 3. Student/Family Member Support:

Did you give the student and/or the student's parent (s) money to pay their bills in year 2017? : YES NO. If yes, to whom student/ parent (s) and how much money did you give student/$________ ( monthly annually) and/or parent(s) $ __________ ( monthly annually)

Did you pay bills on behalf of the student and or/parent(s) in year 2017? _________. If yes, please list what bills you paid, the amount and list the individual for whom the bill was paid on half of.

List Bill/Company

Indicate the amount you paid

monthly annually

monthly monthly monthly monthly monthly

annually annually annually annually annually

Bill paid on behalf of whom? (Student/parent)

Did the student/ parent(s) contribute any financial assistance toward your household in year 2017? YES NO. If yes, how much money did they give? $__________________ ( monthly annually).

Each person signing this form certifies that all the information reported on it is complete and correct. Warning: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.

______________________________________________

Student Signature

Date

___________________________________________________ Spouse/Parent Signature (required, if applicable) Date

______________________________________________ Person Providing Support to Student/Family Date

Submit this form to: UHD Scholarships and Financial Aid |One Main St, Ste. S330 | Houston, TX 77002

Visit the website for instructions on uploading documents: uhd.edu/financial/processing/Pages/document-upload.aspx

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