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Student Low Income Form

The Smart Choice

2021-2022 Student Low Income Form

  • Your (and your spouse's if applicable) reported income for 2019 was unusually low. Please indicate how your household expenses were paid from January 1, 2019 to December 31, 2019. Please enter amounts for all items. If the item does not apply indicate "zero".

  • Expenses for 2019


  • 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 2019


  • 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


  • MM slash DD slash YYYY
  • By signing this worksheet, you are certifying that all information reported on the worksheet is complete and correct.
  • VSLOW1