Dependent Student : In order for your application to be complete, we need your parent/guardian to fill out this form and sign.

OR

Independent Student : In order for your application to be complete, we need you to complete the following information.(An independent student must meet at least one of the following: 24 years old, married, serving active duty in military, foster care or ward of the state, etc. Discuss with SSS staff if you have any questions re: status)  
Student First Name *
Student Last Name *
Parent Name (if student is dependent)

The table below shows the low income amounts based on family size and federal taxable income.
Your federal taxable income can be found on line 15 of the IRS tax form 1040. Please note, this is different than your adjusted gross income.

Size of Family Unit

48 Contiguous States, D.C., and Outlying Jurisdictions

Alaska

Hawaii

1

$23,940

$29,925

$27,540

2

$32,460

$40,575

$37,335

3

$40,980

$51,225

$47,130

4

$49,500

$61,875

$56,925

5

$58,020

$72,525

$66,720

6

$66,540

$83,175

$76,515

7

$75,060

$93,825

$86,310

8

$83,580

$104,475

$96,105

Each additional family member, 48 Contiguous States $8,520, Alaska $10,650, Hawaii $9,795

 
Size of Family Unit *

Please Check One:
Our taxable family income was at or below the amount listed for size of family.
Our taxable family income was above the amount listed for size of family

I verify the above information is accurate.  The below signature is either the parent signature of a dependent student, OR an independent student signature.  

 
Signature *
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Signature: (Type in your full name)
I agree to the terms included.