INDEPENDENT
WINTHROP UNIVERSITY
OFFICE OF FINANCIAL AID
Low Income Verification Statement
2016-2017
Student’s Name _______________________________
Winthrop ID Number __________________________________
E-mail Address _______________________________
Student’s Phone Number _______________________________
The income which you reported on the 2016-2017 FAFSA appears to be unusually low. Please complete this form to
explain how you paid your living expenses in 2015.
Is The Expense/Bill In Your Name?
Living Expenses
Amount Paid
Each Month
(indicate “YES” if your name is listed on the bill)
Source of Payment
(e.g. your earnings, family
member, state agency, etc.)
(please circle)
Housing
Car payment
Credit cards
Insurance
Other expenses
Phone
Utilities
YES
YES
YES
YES
YES
YES
(gas, electric, water, cable)
YES
Clothing
Food
Gas and car maintenance
Medical expenses
TOTAL MONTHLY EXPENSES
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
$
Please provide any additional information that would assist us in determining how your living expenses are paid:
I certify that the information above is true and correct to the best of my knowledge.
Student’s Signature
Revised 03/08/16
Date
Sykes House, 638 Oakland Ave, Rock Hill, SC 29733
(803) 323-2189 (phone) – (803) 323-2557 (fax) – finaid@winthrop.edu
www.winthrop.edu/finaid
Winthrop ID __________________
Page 2
HOUSEHOLD INFORMATION
List the people in your household, including:
• yourself and your spouse if you have one, and
• your children, if you will provide more than half of their support* from July 1, 2016 through June 30, 2017, even
if they do not live with you, and;
• other people if they now live with you and you provide more than half of their support* and will continue to
provide more than half of their support from July 1, 2016 through June 30, 2017.
Support includes money, gifts, loans, housing, food, clothes, car, medical and dental care, payment of college costs, etc.
Write in the name of the college for any household member who will be attending at least half time during the 2016-2017
school year. Do not list a college if the household member is not sure about attending college. Should s/he enroll later,
notify our office in writing, and your application will be updated.
Full Name
Age
Relationship
Self
College
Winthrop University
NOTE – If the number of people listed above, or the number of people in college has changed since you filed your
FAFSA, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
STUDENT’S UNTAXED INCOME INFORMATION
List amounts and sources of untaxed income and benefits received by you and/or your spouse in 2015 (e.g. child support,
contributions to retirement plans, etc.). List amounts for the entire 2015 year, NOT monthly amounts.
Source of Untaxed Income
Payments to tax-deferred pensions and saving plans
(W-2 Form in Boxes 12a through 12d – Codes D,E,F,G,H,S).
Child support you and/or your spouse received for all children. Don’t include foster
care or adoption payments.
Worker’s Compensation or Disability
(do NOT include Social Security benefits or Supplemental Security Income)
Housing, food, and other living allowances paid to members of the clergy and others as
part of compensation for their job
Basic allowance for subsistence (BAS) paid to members of the military
Veteran’s non-education benefits such as Disability, Death Pension, or Dependency &
Indemnity Compensation (DIC) and/or VA Educational work-study allowances
Health Savings Account Deduction (line 25 on IRS 1040)
CONTINUED ON NEXT PAGE
2015 Amount
$
$
$
$
$
$
$
Winthrop ID __________________
Page 3
CHILD SUPPORT PAID
Did you or your spouse pay child support in 2015?
List the name(s) and age of each child for whom child support
was paid:
Yes
No
If yes, how much for the year? $____________
Child’s Name
Child’s Age
FOOD STAMPS
In 2014 or 2015, did you or your spouse or anyone in your household (listed on page 1) receive Food Stamps from the
Supplemental Nutrition Assistance Program (SNAP)?
Yes
No
Note: If Winthrop has reason to believe that the information regarding the receipt of SNAP benefits is inaccurate,
Winthrop may require documentation from the agency that issued the SNAP benefits in 2014 or 2015.
By signing this worksheet, we certify that all of the information reported to qualify for Federal student aid is complete
and correct.
Student’s Signature
Date
Spouse’s Signature (optional)
Date
Submit to Office of Financial Aid; Sykes House; 638 Oakland Ave; Rock Hill, SC 29733 or fax to (803) 323-2557