_Academic Year_

rr
Students Name:______________________________

PID: ______________________________

Address:____________________________________

Date: _____________________________

City:________________________________________

State/Zip:__________________________

Spouses Name:______________________________

Phone:____________________________

Dear Student:
The 2011 income you reported on your 2012-2013 FAFSA appears insufficient to support the number of people in the
household. Complete this form to clarify how you were able to live and support your family during 2011. Explain how
you were able to provide housing, food, utility bills, clothing, etc. Please note that forms submitted with family total
incomes and total expenses reflecting all zeros will not be acceptable, and will delay processing of aid.

Student Income (report annual income for 2011)

Student Expenses (report annual expenses for 2011)

Include financial support from parents and others.

Include spouse income if married.

Include expenses paid by parents and others.

Earnings (W-2s):
Social Security Benefits
Child Support Received
Financial Aid Received
*Expenses paid by others
(including paid by parents)
Cash support received
(including support from parents)
Other (Identify source):
_____________________
_____________________
_____________________

_________
_________
_________
_________
_________
_________
_________
_________
_________

Total 2011 Income:...$_________

Room: -Rent -Own

Utility (electric, phone, water, etc.)
Board (regular meals)
Recreation, entertainment
Medical
Auto maintenance
Major Payments
(auto, insurance, credit card(s), etc.)
Miscellaneous (Identify Type):
_____________________
_____________________
_____________________

________
________
________
________
________
________
________
________
________
________

Total 2011 Expenses:....$________

*Expenses paid by others should include expenses directly related to supporting

you. If your parent is providing support, include those expenses they paid above
and beyond their own expenses. Do not include expenses they would pay to
support themselves even if they were not providing support to you.

Briefly explain your situation: (use and attach a second sheet of paper if necessary)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
By signing this form, I certify that the information provided on this form is complete and correct to the best of my knowledge.

________________________________________
Students Signature
Date

____________________________________________
Spouses Signature
Date

Office of Student Financial Assistance

www.finaid.ucf.edu
An Equal Opportunity and Affirmative Action Institution

-5241
LINC _Indep_12-13-Rev.1/12