2
STUDENT’S (AND SPOUSE’S, IF MARRIED) INCOME & BENEFITS INFORMATION
Check the appropriate box below and
provide the requested information and
documents:
Employer’s Name
2019 Amount
Earned
IRS W-2, 1099
Provided?
Acme Auto Body Shop (example) $2,000.00
Yes
PARENTS’ INCOME & BENEFITS INFORMATION (Dependent Students Only)
Check the appropriate box below and provide the requested information and documents:
I/we used the IRS Data Retrieval Tool to transfer my/our 2019 income information to the FAFSA.
I/we did not (or could not) transfer my/our 2019 income information to the FAFSA using the IRS Data Retrieval Tool. I/we have
attached a copy of my/our 2019 IRS Tax Return Transcript(s).
I was not employed, had no income earned from work in 2019, and did not and was not required to file taxes for 2019. I provided a
copy of my IRS Verification of Non-Filing Letter for 2019.
I/we worked but did not and was not required to file a 2019 Federal Income Tax Return. I/we have listed below the names of all
employers, the amount earned from each employer in 2019, whether an IRS W-2 form or 1099 is provided. I/we listed every
employer
even if the employer did not issue an IRS W-2 or 1099 form. I/we provided copies of all 2019 IRS W-2 and/or 1099 forms
issued to
me/us and provided verification from the IRS of Non-Filing status.
Employer’s Name
2019 Amount
Earned
IRS W-2, 1099
Provided?
Acme Auto Body Shop (example) $2,000.00
Yes
CERTIFICATION AND SIGNATURE
By signing below, I/we certify the information reported on this worksheet is complete and accurate and authorize the Financial Aid Office to
perform necessary electronic ISIR correction on my behalf. I/we agree to provide proof of any information reported on this form or on my
FAFSA or Dream Act. I/we realize that any false statement or failure to give proof when asked may be cause for denial, reduction, withdrawal,
and/or repayment of my financial
aid. I/we also understand if we purposely give false or misleading information I/we may be fined, sentenced
to jail or both. If you are an independent and married student, a spouse signature is optional. If you are a dependent student, one parent must
sign below.
Student signature
Date
Spouse signature (if married) or Parent Signature (if a dependent student) Date
Rev. 5/27/2021 JV
I/we used the IRS Data Retrieval Tool to transfer my/our 2019 income information to the FAFSA.
I/we did not (or could not) transfer my/our 2019 income information to the FAFSA using the IRS Data Retrieval Tool. I/we have
attached a copy of my/our 2019 IRS Tax Return Transcript(s).
I (and, if married, the student’s spouse) was not employed and had no income earned from work in 2019. I have provided a copy of my
IRS Verification of Non-Filing Letter for 2019 (for independent students only).
I (and, if married, the student’s spouse) have income earned from work and not required to file a 2019 income tax return with the IRS.
I have entered all income information below, listing the names of all employers. I have provided copies of all 2019 IRS W-2 forms and/
or 1099 forms. In addition, I have provided a copy of my IRS Verification of Non-Filing Letter for 2019 (for independent students only).
