Low Income Verification Form
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1Low Income Verification Form
Student’s Name_______________________________________________________ Student ID: ____________________________
Last
First
M.I.
The 2012 income you reported on your FAFSA application is unusually low or zero. Clarification as to how you lived on this income
is needed. Your application for financial aid is on hold until you complete and return this form to us. If you are a dependent student,
you must include parental information. Use the back of the form if necessary. If you have any questions, please contact us at
252-862-1200.
Instructions:
1. Provide information regarding income from January 1, 2012 to December 31, 2012.
2. Show how you/parents were able to support yourself/themselves for 2012.
3. List the YEARLY amount received during 2012 for each item.
4. Questions left blank will cause the form to be returned to you for completion.
Student
Spouse
Mother or Stepmother
Father or Stepfather
(if married)
(if dependent student)
(if dependent student)
Wages, Salaries. (money from a
/year
/year
/year
/year
job)
Unemployment Compensation
/year
/year
/year
/year
Workers’ Compensation
/year
/year
/year
/year
Social Security Benefits
/year
/year
/year
/year
Child Support
/year
/year
/year
/year
Alimony
/year
/year
/year
/year
Veteran’s Benefits
/year
/year
/year
/year
Welfare/TANF (Gov’t cash
/year
/year
/year
/year
assistance)
Pension Payments
/year
/year
/year
/year
Food Stamps
/year
/year
/year
/year
Housing Assistance
/year
/year
/year
/year
Any cash from family members,
/year
/year
/year
/year
cash gifts, or money for bills.
1. Do you/parents have any bills’ in your name?
A. If “yes”, please lists all bills and amounts that were incurred during 2012.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
B. Who pays for these bills? _____________________________________________________________________________
2. If you answered “No”, please explain who or how you were able to cover day-to-day living expenses, rent, or house payment, utility
bills, food, clothing and other necessities during 2012.
____________________________________________________________________________________________________________
I/ We certify that all information reported is complete and correct to the best of my ability, and that I have attached relevant
documentation, if applicable. I/We understand that any false statement or misrepresentation will be cause for denial, reduction,
withdrawal, and/or repayment of financial aid and may subject the financial aid recipient to a fine, imprisonment, or both under
provision of the U.S. Criminal Code.
Student’s Signature:_______________________________________ Parent’s Signature:_______________________________________
Date: _____________________________________
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