Submit this completed form and all supporting documents to Lamar State College Port Arthur Financial Aid Office using your preferred method.
Mail: LSCPA Office of Financial Aid ▪ PO Box 310 ▪ Port Arthur, TX 77641 Drop off: 304 Student Center
Scan and email: FinancialAid@lamarpa.edu Fax: 409-984-6021
Revised 10/21/2019
STUDENT DECLARATION THAT A FEDERAL INCOME TAX FORM
WILL NOT BE FILED 2020-2021
Student Information
Name_________________________________________________ ID # _________________________
I
(we) will not file, and am (are) not required to file a federal tax return (includes the 2018 IRS Form 1040, Telefile worksheet, a tax
return from Puerto Rico or a foreign income tax return).
List below all sources of income for 2018 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
TO
TAL
Earnings $ $ $
Social Security Benefits $ $ $
TANF/Welfare $ $ $
Child Support $ $ $
Housing, food, and other
living allowances
(excluding rent subsidies
for low-income housing)
$ $ $
Other: $ $ $
$ $ $
TOTA
L
$
Certification and Signature
I hereby certify that all information contained in this declaration is correct and complete.
WARNING: 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’s Signature Date
