DECLARATION THAT A FEDERAL INCOME TAX FORM WILL NOT BE FILED FOR _________ 

STUDENT’S NAME _________________________________   Social Security No. ________________
                               Last                              First                       Middle  

List below all sources of income for ______________  and attach documentation of that income:

SOURCE

AMOUNT  
STUDENT

AMOUNT  
SPOUSE

TOTAL

Earnings

$

$

$

Social Security Benefits

 

 

 

Child Support

 

 

 

AFDC/Welfare

 

 

 

Housing, food, and other  
Living allowances (excluding  
Rent subsidies for low-income housing)

 

 

 

Other:

 

 

 

 

 

 

 

 

 

Total

$

   

SOURCE

AMOUNT  
MOTHER/STEPMOTHER

AMOUNT
FATHER/STEPFATHER

TOTAL

Earnings

$

$

$

Social Security Benefits

 

 

 

Child Support

 

 

 

AFDC/Welfare

 

 

 

Housing, food, and other  
Living allowances (excluding  
Rent subsidies for low-income housing)

 

 

 

Other:

 

 

 

 

 

 

 

 

 

Total

$

  By signing this worksheet, I (we) certify that all the information reported to qualify for  student aid is complete and correct.

Dependent students:  At least one parent must sign.

 

 

WARNING:  If  you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both

 

   

 

_______________________________________                                  ____________________________________  
STUDENT                                Date                                                        Parent                                    Date

At lease one parent must sign if Dependent Student

 

 

 

If financial resources were less than $4000.00 you must complete Resources Less-Than $4000.00 Form

 

Form Page   Updated 8 July, 2003