MSU Northern does not discriminate on the basis of race, color, national origin, sex, age or disability.
Parent Non-Tax Filer Statement
This form should be used by individuals (parent and/or student) who are not required to file a 2017 US tax return. A separate form
should be completed for each non-filer.
Student Name: SSN/Banner I.D. #:
Your application was selected for review in a process called “Verification.” In this process, MSU Northern will be comparing information from your
application with your financial documents. The law says we have the right to ask you for this information before awarding Federal aid. Complete this
verification form and submit it to the MSU Northern Financial Aid Office, as soon as possible, so your financial aid won’t be delayed.
Note that this form may not be used if the combined income (including college work-study earnings) for calendar year 2017 was more
than $6,300 (single or married filing separately), $9,250 (head of household) or $12,600 (married filing jointly or qualifying widow(er)). If
any of these are applicable, you are required to file a 2017 US tax return before your financial aid can be processed.
List below all of the sources and amounts of income earned from work received from January 1, 2017 through December
31, 2017. You must attach copies of any W-2 form(s) and/or 1099 form(s) received in 2017 for all income sources
listed below.
2017 Income Information: 1/01/17 12/31/17
Source of Income
Amount
$
$
$
$
$
$
$
$
$
$
AUTHORIZATION
By signing this worksheet, I/we certify that I/we did not and am not required to file a 2017 U.S. federal tax
return. In addition, I/we certify that all the information reported to qualify for Federal student aid is complete
and correct.
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail or both.
Father’s (Stepfather’s) Signature Date Mother’s (Stepmother’s) Signature Date
Return this form to: Financial Aid Office; MSU Northern; PO Box 7751; Havre, MT 59501
STUDENT INFORMATION
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