2018-2019 Independent Verification of 2016 Income Information for
Student Nontax Filers
Student Name________________________________
CID____________________
The instructions and certifications below apply to the student and spouse; if the student is
married. Complete this section if the student and/or spouse 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.
Provide a letter of non-filing from the IRS. See instructions on reverse side.
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. Provide a letter of non-filing from the IRS. See instructions on reverse side.
My spouse did not file an income tax return and was not employed in 2016. Provide a
letter of non-filing from the IRS. See instructions on reverse side.
My spouse 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. Provide a letter of non-filing from the IRS. See instructions on reverse side.
Employer’s Name
Annual Amount
Earned in 2016
(Example) ABC’s Auto Body Shop
Total Amount of Income Earned From Work
Provide documentation from the IRS dated on or after October 1, 2017 that indicates a 2016
IRS income tax return was not filed with the IRS.
___________________________________________
Student’s Signature (Required)
________________________
Date