2021-2022 Tax Non-Filer Statement Form Page 1 of 2

Office of Financial Aid Tarleton Center

Stephenville, Texas 76402Phone: (254)968-9070

Fax: (254)968-9600finaid@tarleton.edu

2021-2022 Non Tax Filers Affidavit

___________________________________________ ______________________ Last Name First Name University ID Number

Complete this form if the student and/or parent/spouse is not required to file a 2019 IRS Tax Return.

Last Name First Name M.I. Relationship

Street Address (include apt. number) Phone Number (include area code)

City State Zip

The instructions and certifications below apply to each parent included in the household. Complete this section if the parents will not file and are not required to file a 2019 income tax return with the IRS. *If you are an Independent Student, skip to the next section on Page 2.*

Check the box that applies:

Neither parent was employed and had no income earned from work in 2019.

One or both parents were employed in 2019 and have listed below the names of all employers, the amount earned from each employer in 2019, and whether an IRS W-2 form is provided. [Provide copies of all 2019 IRS W-2 forms issued to the parents by their employers]. List every employer even if the employer did not issue an IRS W-2 form.

If more space is needed, provide a separate page with the student’s name and ID number at the top.

Employer’s Name 2019 Amount Earned

IRS W-2 Provided?

Suzy’s Auto Body Shop (example) $2,000.00 Yes

Step 1 – 2021-2022 Tax Non-Filer Statement

Step 2 – 2019 Income Information for Parent Tax Non-Filers

2021-2022 Tax Non-Filer Statement Form Page 2 of 2

Date Received

Office of Student Financial Aid

______________________________________________ ______________________ Last Name First Name University ID Number

The instructions and certifications below apply to the student. Complete this section if the student/spouse will not file and is not required to file a 2019 income tax return with the IRS.

Check the box that applies:

The student/spouse was not employed and had no income earned from work in 2019.

The student/spouse was employed in 2019 and has listed below the names of all employers, the amount earned from each employer in 2019, and whether an IRS W-2 form is provided. [Provide copies of all 2019 IRS W-2 forms issued to the student by their employers]. List every employer even if the employer did not issue an IRS W-2 form.

If more space is needed, provide a separate page with the student’s name and ID number at the top.

Employer’s Name 2019 Amount Earned

IRS W-2 Provided?

Suzy’s Auto Body Shop (example) $2,000.00 Yes

Each person signing below certifies that all of the information reported is complete and correct. The student and one parent whose information was reported on the TASFA must sign and date. If you are an Independent student, only the student signature is required.

Student’s Signature Date

Parent’s Signature Date

WARNING: If you purposely give false or

misleading information you may be fined, be

sentenced to jail, or both.

Step 3 – 2019 Income Information for Student Tax Non-Filers

Step 3 – Certification and Signature