Income Certification 2021-22

Student Name*

First Middle Last

Social Security Number (last four digits only)*

Student ID*

Upon reviewing the results of your Free Application for Federal Student Aid (FAFSA), we note that your income is unusually low. Please complete the following information so that we may determine how you supported yourself and/or your dependents.

Do you and your dependents live with your (or your spouse’s) parents?*

Yes
No

Do you and your dependents live with someone other than a parent who provides for your basic necessities (food, shelter, clothing, etc.)?*

Yes
No

Please list the people who provide support and your relationship to them:*

Name	Relationship to Student

Do you (or your spouse) currently receive any of the following:

TANF
Food Stamps
WIC
Untaxed Social Security Benefits
Medicaid
Section 8 housing/Public Housing
Daycare Assistance

Please provide the estimated amount of Untaxed Social Security Benefits for 2021*

Please describe any other assistance that you receive

Are you or your spouse currently employed?*

Yes
No

What are your total estimated wages for 2021?*

Does someone pay bills in your (your spouse’s) name on your behalf?*

Yes
No

What is the total estimated amount paid on your behalf?*

If you (your spouse) have additional information related to how you financially support yourself or your dependents, please explain:

My signature certifies that the information provided is true and correct and that I am providing an accurate description of my financial situation. I understand that purposely giving false or misleading information could result in a fine, imprisonment or both as it relates to my reporting information to the U.S. Department of Education.

Student Signature*