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Student Low Income

The Smart Choice

2020-2021 Student Low Income Form

  • Your (and your spouse's if applicable) reported income for 2018 was unusually low. Please indicate how your household expenses were paid from January 1, 2018 to December 31, 2018. Please enter amounts for all items. If the item does not apply indicate "zero".

  • Expenses for 2018


  • Housing


  • Rent/Mortgage


  • Utilities


  • Electricity/Gas


  • Water/Sewer


  • Transportation


  • Car Note


  • Insurance


  • Fuel


  • Personal


  • Food


  • Medical


  • Daycare

  • Total Expenses

  • Please explain in the case that an item that was not required for all 12 months or was not required at all.
  • Income for 2018


  • Earned income from W-2s, business or farm


  • Unemployment Compensation


  • TANF, AFDC, etc.


  • Food Stamps


  • Housing Assistance


  • Social Security Income


  • Disability Income


  • Workman's Compensation


  • Financial Aid/Scholarships


  • Child Support


  • Medicaid


  • Other


  • If the total amount of expenses is greater than your total incomeplease explain how this expense was provided for.
  • Student Consent


  • Date Format: MM slash DD slash YYYY
  • By signing this worksheet, you are certifying that all information reported on the worksheet is complete and correct.
  • VSLOWO