2019-20 VERIFICATION OF NON-EMPLOYMENT INCOME
Please complete this form on a computer, or use black or blue ink.
STUDENT NAME _____________________________________ CCC ID# OR LAST 4# OF SSN __________________
PLEASE HAVE YOUR SPOUSE (IF APPLICABLE) COMPLETE A SEPARATE FORM WITH THEIR INFORMATION IF THEY DID NOT WORK
IN 2017.
S
POUSE NAME:_______________________________________________________________________________
YOU INDICATED ON YOUR FAFSA THAT YOU HAD NO INCOME FROM WORK. CHECK ALL THAT APPLY:
I did not file a 2017 Federal Income Tax form.
I am not required to file a 2017 Federal Income Tax form because I had no income in 2017.
Income information was incorrectly reported on my FAFSA. I had work income in 2017. Attached are
copies of my 2017 W-2 forms.
I R
ECEIVED THE FOLLOWING PUBLIC ASSISTANCE (MY FAMILY INCLUDED, IF APPLICABLE) IN 2017 OR 2018:
ADC/AFDC VA Benefits (specify) $___________________
Food Stamps Workman’s Compensation
Medicaid/Untaxed Social Security Benefits Other_________________________________
I WAS SUPPORTED IN 2017 BY:
Family Member Name_____________________________________Relationship__________________
Friend/Significant Other Name__________________________________________________________
PLEASE PROVIDE A BRIEF STATEMENT OF HOW YOU WERE SUPPORTED.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Each person signing below certifies that all of the information reported is completed and correct. An electronic
signature is not valid.
___________________________________________________________
STUDENT SIGNATURE DATE
___________________________________________________________
SPOUSE SIGNATURE (IF APPLICABLE) 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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