2018-2019 Dependent Verification of 2016 Income Information for
Student Nontax Filers
Student Name________________________________ CID
____________________
The instructions and certifications below apply to the student. Complete this section if the
student will not file and are not required to file a 2016 income tax return with the IRS.
Check all boxes that apply:
I (the student) did not file an income tax return and was not employed in 2016.
I (the student) did not file and was not required to file, but was employed in 2016.
Provide all W-2s or an IRS Wage & Income Transcript. Please complete the table below listing each
source of income.
Employer’s Name
IRS W-2
Provided?
Annual Amount
Earned in 2016
(Example) ABC’s Auto Body Shop Yes $4,500.00
Total Amount of Income Earned From Work $
___________________________________________
Student’s Signature (Required)
________________________
Date
