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2013-2014 Minimal Income Statement Form (LIVE Form) Independent

You reported an unusually low amount of household income on your 2013-2014 Free Application for Federal Student Aid (FAFSA). In order to document how the household was maintained on this amount of income, please complete this form.

Independent Students need to complete information regarding student (and spouse, if married) only. If any question is left unanswered, this form will be returned to you, which will delay your application process.

Fields marked with an asterisk (*) are required fields

Independent Student's Information
First Name: *
Last Name: *
NLU ID Number: * (Example: N00123456)
Date of Birth: * / /
Address: *
City: *
State: *
Zip: *
Email: *
Phone Number: *
Alternate Phone Number:
Income and Support

Please be specific and report information for the calendar year 2012, not the current year.

Source of Income and Support: Student (and Spouse, if married)
Amount Received for the Year 2012
Student's Income from work.
(Provide all W2s)
Spouse's Income from work.
(Provide all W2s)
Unemployment $
Workman's Comp $
Food Stamps $
Child Support $
Financial Aid used for Living Expenses                Amount: $
Parent/Other Relatives/Friend $
Disability $
Welfare $
Veteran's Non-education Benefits $
Other Source $

To be completed by Student (and Spouse, if married):

Who provides the following to the Student? Amount per month From what source is this being paid? (i.e. I lived with aunt; money earned from my job; I lived with friend)
Car expenses, Gas, Insurance, Bus fare $ * *
Rent/Mortgage $ * *
Utilities $ * *
Food $ * *
Personal Care (clothing, hygiene, etc.) $ * *
Use the space below to provide additional comments needed to explain how the household was maintained on the reported income and to report changes in income and/or living accommodations.
Certification and Signature
By printing my name below, I certify that all the information reported to qualify for student financial aid is true and accurate. You understand that if this form is incomplete, your aid will be delayed.
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
Student Signature: *
Spouse Signature:

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