OFFICE OF FINANCIAL AID, 333 North College Way
Sumner Hall , Claremont, CA 91711
Email: [email protected], P: (909) 621-8205, F: (909) 607-7941
2017/2018 AWARD YEAR
STUDENT STATEMENT OF NON-FILING TAX STATUS FOR 2015
If you have filed, or will file, a Federal Income Tax Return (1040, 1040A, or 1040EZ) for 2015, you must provide a
signed copy of the return, including all schedules and W-2 Forms, to our office. If you did not keep a copy, you
should request a copy from your tax preparer or request a transcript (Form 4506-T), from the Internal Revenue
Service at 1-800-829-1040. DO I HAVE TO FILE A RETURN?: To determine if you are required by law to file,
obtain a federal tax return booklet at your local post office or library, or visit the IRS website at www.irs.gov.
If you did not file, and are not required to file, a Federal Income Tax Return for 2015, please complete the following
information and return the form to this office immediately. In addition, please attach copies of your W-2s and/or
any other supporting income documents. If you had no income for 2015, please place a zero in the “Amount”
column in the grid below.
____________________________________________________________________________________________
I certify that I will not file, and am not required to file, a Federal Income Tax Return for 2015. I have listed below
the amounts and sources of all income I received for 2015*. DO NOT INCLUDE TAXABLE SCHOLARSHIP.
Source of Funds
Type of Income*
EXAMPLE: McDonald’s
EXAMPLE: Bank of America
Wages
Taxable Interest
TOTAL
Amount
$ 700.00
$ 10.00
$
$
$
$
I hereby certify that all information reported on this form, and any attachments, hereto, is true, complete, and
accurate. False statements or misrepresentations will be cause for denial, reduction, withdrawal, and/or repayment
of financial aid.
Student’s Name (Print)
Student’s Signature
Date
Student’s ID Number (if known)
*Income listed should include all wages (including need-based student earnings), earnings on savings and
investments reported on Form 1099, all sources of untaxed income (i.e., Social Security benefits, TANF, et cetera),
and the amount of money received from all other sources for 2015. DO NOT INCLUDE TAXABLE
SCHOLARSHIP.
forms\nonfile
10/26/2016