Office of Student Financial Aid
Phone: 1-800-283-4243
(417) 836-5262
Fax: (417) 836-8392
Email: [email protected]
901 S National Avenue
Springfield, MO 65897
2017-2018 Student Non-Filing Statement
Student’s Name (Last)
M
BearPass #
(First)
Student’s Date of Birth
COMPLETE ALL SECTIONS
This form is to be completed by the student to verify information reported on your Free Application for Federal Student Aid (FAFSA).
Complete this form if you (the student) and/or your spouse will not file, and are not required to file, a 2015 Federal Income Tax
Return. To determine if you are required to file a 2015 Federal Income Tax Return please refer to IRS Publication 17 for 2015.
A. Student Information
1.
2.
What is your marital status? (check one)
□ Single (separated, divorced, widowed, never married)
□ Married (married, remarried)
Did you (or your spouse) file a 2015 tax return, or are you required to file a 2015 tax return? (check all that apply)
□ Yes. (Submit a copy of yours (or your spouse’s) 2015 Federal Tax Return Transcript to our office.)
□ No. (Continue to Section B). If your spouse did not file they must submit a Spouse Non-Filing Statement
B. 2015 Income Information
List your employer(s) and work income received in 2015 on the table below. Include all earnings from work, even if a W-2 was not
received. Enter “0” if none; do not leave any blank lines.
WAGE EARNER’S NAME
EMPLOYER’S NAME
2015 WORK INCOME EARNED
$
$
$
$
C. 2015 Income Documentation
Be sure to attach copies of all 2015 income documentation for earnings listed above. This includes Form W-2’s, 1099’s, and other
earnings documentation.
1.
2.
Number of W-2’s attached: _____
Number of other forms attached:
Type of Form: __________ Number Attached:
Type of Form: __________ Number Attached: _______
Type of Form: __________ Number Attached: _______
D. Certification Statement & Signature
By signing below, I acknowledge that I have read and understand the information on this form, that I have appropriately attached all
supporting documents, and certify that all information submitted is accurate and true to the best of my knowledge. I understand that
submitting this form does not guarantee that my request will be granted.
________________________________________
_________________________________
Student’s Signature
Date
________________________________________
_________________________________
Spouse’s Signature
Date