Qualtrics Survey | Qualtrics Experience Management

To complete your SSS eligibility information, we need to have additional documentation on your family income from last year. Please complete the questions below, based on your household income information and return it to us. Thank you!

Name of student:

Are you an independent student?

Note: To be considered “independent,” students must meet one of the following criteria: at least 24 years of age; married; a veteran or member of the armed forces; an orphan; a ward of the court; someone with legal dependents; an emancipated minor; or someone who is homeless or at risk of becoming homeless.

Yes
No

Name of parents:

Did your household file a 2023 federal tax return?

Yes
No

Did your parent or someone else claim you as a dependent on their 2023 federal tax return?

Yes
No

How many individuals were in your household in 2023?

My family's taxable income (line 15 on the 1040 federal income tax form) for 2023 was:

Additional comments:

I certify that the information I provided on this form is accurate.

Parent or guardian signature

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Student signature

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