Form V6 - Low Income Verification

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Low Income Verification Form (V6)
You were selected for verification by the federal processor due to the low income reported on your
FAFSA. Please complete this form and return it to the Financial Aid Office to be considered for aid. For
dependent students the parent’s income information is required.
Name ________________________________________________________________
SSN or BRCC ID_________________________________
Date of Birth ___________________
Sources of Income:
2014 US Income Tax Return Adjusted Gross Income:
$_________________
Are you currently employed?
If yes: Employer ________________________
$____________/month
When did your employment begin? ________________
I used savings/retirement to pay for 2014 living expenses? ___Yes ___No
$____________/year
Did you receive any of the following Untaxed Income in 2014?:
Unemployment:
___Yes ___No
$____________/week
Untaxed Social Security Income:
___Yes ___No
$____________/month
Child Support:
___Yes ___No
$____________/month
Disability:
___Yes ___No
$____________/month
Alimony:
___Yes ___No
$____________/month
Housing:
Which best describes your current housing situation?
I live:
_____ with Parent(s) & they pay for housing
_____ with a Friend/Relative & they pay for housing
_____ in a rental
Rental:
$____________/month
_____ in my own home
Mortgage:
$____________/month
Are you receiving public housing assistance?
____ Yes
____ No
$____________/month
Basic Living Assistance:
Food:
Do you receive SNAP (Food Stamps)?
____ No
____ Yes
$_____________/week
Do you receive WIC Benefits?
____ No
____ Yes
$_____________/week
Does a parent or other person provide?
____ No
____ Yes
$_____________/week
Utilities, Who Pays?:
Electricity
____ Self
____ Parent
____ Other
$____________/month
Water
____ Self
____ Parent
____ Other
$____________/month
Telephone
____ Self
____ Parent
____ Other
$____________/month
Cable/Internet ____ Self
____ Parent
____ Other
____ NA $____________/month
Signature _______________________________________________
Date_________________

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