2021-22 NON-FILING AFFIDAVIT
Submit this document in-person, by email to finaid@kilgore.edu, by fax to 903-988-7528 or by mail to KC Financial Aid, 1100 Broadway, Kilgore, TX 75662.
Student Name: ______________________________________________ Student ID/SSN: _______________________
This form will serve as the Kilgore College Financial Aid Office’s acceptable substitute for IRS Form 4506-T. Students, spouses or
parents who indicate on the FAFSA they had earnings, but did not file taxes, should complete this form. Students, spouses or parents
who did not file taxes for the selected tax year, but indicated on the FAFSA that they did file taxes, should complete this form.
Dependent students are not required to obtain proof of non-filing UNLESS the FAFSA indicated “Will File” or “Completed” a tax return
and this was done in error. Each form must be notarized. Each person must provide a valid government-issued ID to the notary and
must sign this page in the presence of the notary.
Federal Register / Vol. 85, No. 172 / Thursday, September 3, 2020 / Notices
For an individual who has not filed and, under IRS or other relevant tax authority rules (e.g., the Republic of the Marshall Islands, the Republic of Palau, the Federated
States of Micronesia, a U.S. territory or commonwealth or a foreign government), is not required to file a 2019 income tax return—
(1) A signed statement certifying—(a) That the individual has not filed and is not required to file a 2019 income tax return; and (b) The sources of 2019 income earned
from work and the amount of income from each source;
(2) A copy of IRS Form W–2 for each source of 2019 employment income received or an equivalent document; and
(3) Except for dependent students, verification of nonfiling from the IRS or other relevant tax authority dated on or after October 1, 2020.
Tax year __2019__
Who:
Student
Spouse
Parent (name) _______________________________________
The person above:
Tried to obtain verification of non-filing from the IRS, but was unable to.
Student has not filed and is not required to file a tax return due to non-taxable income received (SSI, Social Security, TANF,
etc. - Documentation of benefit must accompany this form)
o Benefit received:________________________________
Had no earnings and was not required to file taxes for the above tax year.
Had earnings, but was not required to file taxes for the above tax year.
o Person with earnings who did not file must submit proof of earnings such as W-2 Forms, 1099 forms, etc.
Certification and Signature - Signature must be completed in the presence of a Notary Public and signer must present valid
identification to the Notary Public.
I certify by signing this document that all of the information on this form is complete and true.
Warning: If you purposely give false or misleading information, you may be fined, sentenced to jail, or both.
Signature ____________________________________________ Date ___________________
This section must be completed by a Notary Public.
BEFORE ME, the undersigned authority, on this day personally appeared __________________________ and being by me first duly
sworn, did state under oath the following:
My name is _______________________________________________. I am fully competent and authorized to make this affidavit
based on my personal knowledge.
SUBSCRIBED and SWORN to before me by the said affiant, this _______day of _______________________, ___________.
(Affix Seal)
__________________________________
NOTARY PUBLIC, STATE of _________
