Independent Non-Tax Filer Form

Independent Non-Tax Filer Form
2016-2017
____________________________________________
Student’s Legal Name
_______________________________
Student ID Number
To help us to better understand your monthly financial situation, please complete the following:
Monthly
Resources
Work Income
Amount
Monthly Expenses
Amount
Housing
SNAP (Food
Stamps)
Child Support
Received*
Credit**
Transportation
Gifts***
Medical
Other****
Other
Total
Total
Utilities
Food
*Please report Child Support received for the entire household on a monthly basis.
**Please report any personal credit (i.e. credit cards, personal loans, etc…) used each month to meet monthly living expenses.
***Gifts are cash received or payments made on your behalf for housing, food, utilities, transportation, medical, and other expenses. You should
estimate expenses paid on your behalf at fair market value.
****Sources of untaxed income other than income earned from work or gifts (i.e. clergy or military housing living allowances, etc…).
Additional Information
1. If you have resources reported in the ‘Other’ category in the resources grid above, please explain what
kind of income it is (Ex: Interest Income, Money Paid on Your Behalf, etc…).
______________________________________________________________________________
______________________________________________________________________________
2. In 2015, did you live with one or more individuals who helped or provided you with support to meet
monthly expenses?
Yes
No
If so, please explain your situation:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Additional Information (continued)
3a. Please check one of the following:
I have attached my W-2’s to this form as proof of my income.
I worked but did not receive a W-2. (Complete 3b. below)
I did not work.
3b. If you worked but did not receive a W-2, please disclosure your employment information below.
Employer
Amount Earned
__________________________________________
________________________
__________________________________________
________________________
__________________________________________
________________________
Of the amount stated above, my 2015 income from IWU student employment was $__________.
4. If you have other circumstances that are not addressed by the requested information above, please
detail those circumstances below.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Student Certification
I have not filed and will not file a 2015 Federal income tax return 1040/1040A/1040EZ. All information
on the Student Aid Report which will be used to calculate my eligibility for student assistance is complete
and correct.
________________________________________
___________________________
Student’s Legal Name
Student ID Number
________________________________________
___________________________
Student’s Signature
Date
**Please be sure to send in a copy of your W-2’s along with this form, if you
earned any income from an employer in 2015. **