2023-2024 Form 54 Low Income Statement

Campus Location *

As noted on your Student Aid Report, the Department of Education has asked Heritage University to collect information from you that explains how you and/or your parents lived on the income you listed on your Free Application for Federal Student Aid.

Name*

First NameLast Name

Student ID*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Please select your Dependency Status below:*

Your Parent is required to sign this worksheet. Please enter their contact information below. They will receive an email inviting them to complete their portion of this form and add their electronic signature. Please remind them to check their Junk email folder if the invitation does not arrive in their Inbox. This form cannot be processed without their signature.

Name

First NameLast Name

Email

example@example.com

List your total annual expenses for 2021

	Parent's Annual Amount	Student's Annual Amount
Rent (amount paid for the year, not by month)
Utilities (Lights/Water/Heat amount paid for the year, not by month)
Food Expenses (amount paid for the year, not by month)
Transportation (amount paid for the year, not by month)
Cell Phone Bill (amount paid for the year, not by month
Car Insurance/Car Note (amount paid for the year, not by month)

Name of Person who provided Rent/Food/Utilities if paid for by someone other than parent/student.

List all income and resources for 2021

	Parent's Annual Amount	Student's Annual Amount
Student's Earned Income (if applicable)
Father's Earned Income (if applicable)
Mother's Earned Income (if applicable)
Unemployment Compensation
Child Support/Maintenance Support
Pensions/Disability
Other Untaxed Income
Public Assistance TANF/GUA
Food Stamps/Funding for Food
Social Security/SSI (amount received for the year, not by month....also upload "2021 End of Year Statement" as proof of benefits received )
Rent/Food/Utilities Provided by Another Individual
Cash support from friends or relative (Include payments made on behalf of you/your spouse/your parents for rent, utilities, etc.)

Source of "Other Untaxed Income" (only provide if listed an amount in "Other Untaxed Income" field above).

List your total expenses for 2021

	Student's Annual Amount
Rent (amount paid for by year, not by month)
Utilities for House (Lights/Water/Heat, amount paid for the year, not by month)
Food Expenses (amount paid for the year, not by month)
Transportation (amount paid for the year, not by month)
Cell Phone Bill (amount paid for the year, not by month)
Car Insurance/Car Note (amount paid for the year, not by month)

Name of Person who provided Rent/Food/Utilities if paid by someone other than student.

List all income and resources for 2021

	Student's Annual Amount
Student's Earned Income (if applicable)
Spouse's Earned Income (if married)
Unemployment Compensation
Child Support/Maintenance Support
Pensions/Disability
Other Untaxed Income
Public Assistance TANF/GUA
Food Stamps/Funding for Food
Social Security/SSI (amount received for the year, not by month....also upload "2021 End of Year Statement" as proof of benefits received )
Rent/Food/Utilities Provided by Another Individual
Cash support from friends or relative (Include payments made on behalf of you/your spouse/your parents for rent, utilities, etc.)

Source of "Other Untaxed Income" (only provide if listed an amount in "Other Untaxed Income" field above).

Use the area below to provide any additional information that would clarify how you met your living expenses.

I certify that the above is a true and complete statement of my personal circumstances. I accept the responsibility to inform the Office of Financial Aid and Scholarships of changes to the above financial data as they occur. *

Date

Financial Aid Office Contact Information

Address: ATTN: Financial Aid Office 3240 Fort Rd., Toppenish, WA 98948 | Phone: (509) 865-8502 | Email: financial_aid@heritage.edu

2023-2024 Form 54 Low Income Statement

Student Information

Dependency Status

Parent Information

Expenses and Income for 2021

Statement

Signature