Revised 02/27/2019
Office of Student Financial Aid – Lamar State College Port Arthur
MEMBER THE TEXAS STATE UNIVERSITY SYSTEM
TM
STUDENT DECLARATION THAT A FEDERAL INCOME
TAX FORM WILL NOT BE FILED 2019-2020
Name_______________________________________________________ Student ID #____________________
I (we) will not file, and am (are) not required to file a federal tax return (includes the 2017 IRS Form
1040, 1040A, 1040EZ, Telefile worksheet, a tax return from Puerto Rico or a foreign income tax return).
List below all sources of income for 2017 and attach documentation of that income:
Please complete all sections. If the amount received is zero dollars, enter $0
SO
URCE
AMOUNT
STUDENT
AMOUNT
SPOUSE
TOTA
L
Earnings
$ $ $
Social Security Benefits
$ $ $
TANF/Welfare
$ $ $
Child Support
$ $ $
Housing, food, and other
living allowances
(excluding rent
subsidies for low-income housing)
$ $ $
Other:
$ $ $
$ $ $
TOT
AL
$
Certification and Signatures
By signing this worksheet, I (we) certify that all the information reported is complete and correct. Caution:
please provide accurate information.
WA
RNING: According to Federal Laws, if you purposely give false or misleading information on this worksheet, you
may be fined, be sentenced to jail, or both.
_________________________________________ ______________________________________
Student’s Signature Date Spouse Signature (Optional) Date
