Statement for Students Not Filing a 2017 Federal Tax ...

[Pages:1]Bentley University Office of Financial Assistance

175 Forest Street Waltham, MA 02452-4705

phone (781) 891-3441 fax (781) 891-2448

Statement for Students Not Filing a 2017 Federal Tax Return 2019-2020 Academic Year

Student's Name:________________________________________ Student ID: _________________

Your Free Application for Federal Student Aid (FAFSA) indicated that you will not file a 2017 federal income tax return. This form is designed to collect calendar year 2017 income information for nonfilers. Please complete this form, sign it, and return it to the Office of Financial Assistance.

Use the spaces below to report all income received during the calendar year 2017 from all sources including but not limited to: income from work, interest and/or dividend income, Social Security, etc.

Check this box if you had no income in 2017 and please write "none" in the source of income column below.

Source of student income, benefits and/or assistance received in 2017 _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________

Amount of income received from each source in 2017 $____________________ $____________________ $____________________ $____________________ $____________________ $____________________

Attach copies of supporting documentation such as W-2 forms, 1099 forms, or any forms that document the amount of untaxed income that you received for the calendar year 2017, such as Social Security benefits, AFDC benefits, etc.

Certification and Signature(s) I certify that I have not, will not, and am not required to file a 2017 U.S. or Puerto Rico Income Tax return (1040/1040A/1040EZ/1040tel), and that the income information reported above is complete and accurate.

___________________________________ Student Signature ___________________________________ Spouse Signature (if married, see below)

____________________ Date ____________________ Date

Attention married students: If you were married at the time your 2019-2020 FAFSA was filed and your spouse did not file a 2017 return, report income for you and your spouse on this form, and have your spouse sign in the space above. If your spouse did or will file a 2017 return, report only your income on this form and submit a copy of your spouse's return with this form.

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