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2012 - 2013 Low Income Form

Dear Financial Aid Applicant,
When reviewing your 2012/2013 Student Aid Report, we noted that a low or zero 2011 income was reported by you or your parent(s). Clarification as to how you lived on this income is needed. Please answer the questions below and return this form to the Bellevue University Financial Aid Office WITHIN 14 DAYS. This information is required prior to the processing of your financial aid.

If you have any questions regarding the completion of this form, please contact the OneStop Service Center at (800) 756-7920 / (402) 293-2000, option 0 or by email at OneStop@bellevue.edu. Thank you for your cooperation and prompt response.

2011 Expenses (indicate approximate annual amount)

Housing Expense

$

Did you receive housing assistance?

Utility Expense

$

Did you receive Utility assistance?

Food Expenses

$

Did you receive food stamps?

Medical/Dental Expenses

$

Did you receive medical assistance?

Daycare for children 12 & under Expenses:

$

Did you receive daycare assistance?

Clothing Expenses

$

Recreation Expenses

$

Transportation Expenses

$

2011 Income Sources (indicate approximate annual amounts)

Income earned from work

$

Financial Aid used for living expenses

$

Monetary gifts from friends/family

$

Child support received

$

AFDC/ADC/TANF received

$

Social Security

$

Worker Compensation

$

Disability

$
$

Other (please specify below)

$
$

Certification

By signing this worksheet, I (we) certify that all the information reported to qualify for Federal student aid is complete and correct.

Warning: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.

$
$
$
$

Please ensure your email address is formatted correctly in order to receive a courtesy copy.

Thanks for your interest in Bellevue University.

When you click the submit button below, our staff will contact you within 48 hours to get you the information you need and answer any questions.

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