2019-20 VERIFICATION OF INCOME FOR NON-TAX FILERS
Please complete this form on a computer, or use black or blue ink.
S
TUDENT NAME____________________________________ CCC ID# OR LAST 4# OF SSN_____________
You provided information on your FAFSA indicating you or someone in your household earned income
from work in 2017 but a Federal Income Tax form will not be submitted. As part of the verification
process, you must provide the following information for that individual:
___________________________________________________________________________________
N
ON-FILER NAME (IF NOT STUDENT) RELATIONSHIP TO STUDENT
C
HECK ALL THAT APPLY FOR THE NON-FILING PERSON:
I did not file a 2017 Federal Income Tax form.
I am not required to file a 2017 Federal Income Tax form based on my income earned in 2017.
Income information was incorrectly reported on my FAFSA. I was not employed in 2017 and
had no work income.
I had work income in 2017. Attached are copies of my 2017 W-2 forms.
List every employer even if the employer did not issue you an IRS W-2 form.
E
MPLOYER 2017 Work Income
Did you receive a
W-2 form?
Total Amount of Income Earned from Work $
Signing below certifies that all of the information reported is complete and correct. An electronic
signature is not valid.
__________________________________________________________
N
ON-FILER SIGNATURE DATE
Please return this form to the Financial Aid Office at the location you plan to attend:
Central Community College Columbus PO Box 1027 Columbus, NE 68602-1027 Fax: 402-562-1290
Central Community College Grand Island PO Box 4903 Grand Island, NE 68802-4903 Fax: 308-398-7407
Central Community College Hastings PO Box 1024 Hastings NE 68902-1024 Fax: 402-461-2447
Central Community College Kearney PO Box 310 Kearney, NE 68848-0310 Fax: 308-338-4041
WARNING: If you purposely give
false or misleading information,
you may be fined, sent to prison,
or both.
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