University of Arkansas
Little Rock
TRIO Student Support Services
2801 S. University Ave., Little Rock, AR 72204
(501) 569-683-7481
Income Verification Statement
Independent Student
I, __________________________________, do hereby certify, that after exemptions
and deductions, my taxable/nontaxable income for the year ______________ is
___________________.
Number in Family/Household____________________.
__________________________________ ___________________________
Student Signature Date
The TRIO Student Support Services Program is 100% federally funded by the U. S. Department of Education.
Revised 4/19
