2019-20 VERIFICATION OF PARENT(S) NON-EMPLOYMENT INCOME
Please complete this form on a computer, or use black or blue ink.
S
TUDENT NAME _____________________________________ CCC ID# OR LAST 4# OF SSN __________________
PARENT(S) NAME:____________________________________________________________________________
Y
OUR PARENT(S) INDICATED ON YOUR FAFSA THEY HAD NO INCOME FROM WORK. HAVE YOUR PARENT(S) CHECK ALL
THAT APPLY
:
My parent(s) did not file a 2017 Federal Income Tax form.
My parent(s) is not required to file a 2017 Federal Income Tax form because they had no work
income in 2017.
Income information was incorrectly reported on my FAFSA. My parent(s) had work income in 2017.
Attached are copies of their 2017 W-2 forms.
MY PARENT(S) RECEIVED THE FOLLOWING PUBLIC ASSISTANCE FOR 2017 OR 2018:
ADC/AFDC VA Benefits (specify) $___________________
Food Stamps Workman’s Compensation
Medicaid/Untaxed Social Security Benefits Other_________________________________
MY PARENT(S) SUPPORT IN 2017 WAS MADE AVAILABLE BY:
Family Member Name_____________________________________Relationship__________________
Friend/Significant Other Name__________________________________________________________
PLEASE HAVE YOUR PARENT(S) PROVIDE A BRIEF STATEMENT OF HOW THEY SUPPORTED THEIR FAMILY.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Signing below certifies that all of the information reported is complete and correct. One parent whose
information was reported on the FAFSA must sign and date. An electronic signature is not valid.
_____________________________________________________________
P
ARENT 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,
