2013-2014 Student Low Income

Student Information Student Name Student ID #

Your (and your spouse's) reported income for 2012 was unusually low. Please indicate how your household expenses were paid from January 1, 2012 to December 31, 2012. Please enter amounts for all items. If the item does not apply indicate "zero".

In 2012 I lived (check one) With Parent On Campus Off Campus

Expenses for 2012

Housing

Rent/Mortgage Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Utilities

Electricity/Gas Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Water/Sewer Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Transportation

Car Note Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Insurance Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Fuel Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Personal

Food Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Medical Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

Daycare Amount per Month $ Number of Months Yearly Total $ From what source was this paid?

TOTAL EXPENSES Yearly Total $

Please explain in the case that an item that was not required for all 12 months or was not required at all.

Name:

Income for 2012

Earned income from W-2s, business, or farm Amount per Month $ Number of Months Yearly Total $

Unemployment Compensation Amount per Month $ Number of Months Yearly Total $

TANF, AFDC, etc. Amount per Month $ Number of Months Yearly Total $

Food Stamps Amount per Month $ Number of Months Yearly Total $

Housing Assistance Amount per Month $ Number of Months Yearly Total $

Social Security Income Amount per Month $ Number of Months Yearly Total $

Disability Income Amount per Month $ Number of Months Yearly Total $

Workman's Compensation Amount per Month $ Number of Months Yearly Total $

Financial Aid/Scholarships Amount per Month $ Number of Months Yearly Total $

Child Support Amount per Month $ Number of Months Yearly Total $

Other Source
Amount per Month $ Number of Months Yearly Total $

TOTAL INCOME Yearly Total $

If the total amount of expenses is greater than your total income please explain how this expense was provided for.

I certify that the information on this form is true and correct by signing with either an original or electronic signature.

Student's Signature: ________________________________________ Date:

Complete, print, and return completed form to:

Office of Financial Aid
Box 93260 MSU
Lake Charles, LA 70609
Phone: (337) 475-5065
Fax: (337) 475-5068
E-mail: finaiddocs@mcneese.edu