19MTAXEX 1/11/2019
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
Student Name: _____________________________________________________________
Last Name First Name MI
HCC Student ID: ______________________________
For an individual who is required to file a U.S income tax return and has been granted a filing
extension by the Internal Revenue Service (IRS) for 2017, please submit the following:
A copy of IRS Form 4868, ”Application for Automatic Extension of Time to File U.S. Individual
Income Tax Return,” that you filed with the IRS for the 2017 tax year
A copy of the IRS's approval of an extension beyond the automatic six-month extension if the
individual requested an additional extension of the filing time for tax year 2017
Verification of Non-filing Letter (confirmation that the tax return has not yet been filed) from the
IRS or other relevant tax authority dated on or after October 1, 2018
A copy of IRS Form W-2 for each source of employment income for you and your spouse OR
If you are self-employed, submit a signed statement certifying the amount of AGI and the
U.S. income tax paid for the 2017 tax year
Please check who requested and was granted a tax extension:
Student (and/or Spouse)
Parent(s) Parent must sign below if they have requested an extension.
Student Signature: _________________________________________________________
Date: ______________________________
Parent Signature: ___________________________________________________________
(Required for Dependent Students)
Date: _____________________________
Student Financial Aid Office
11400 Robinwood Drive
Hagerstown, MD 21742
finaid@hagerstowncc.edu
FAX: 301-791-9165
2019-2020
Tax Extension Form
Student Financial Aid Office
11400 Robinwood Drive
Hagerstown, MD 21742
Phone: 240-500-2473
finaid@hagerstowncc.edu
FAX: 301-791-9165
