Confirmation Of Federal Tax Extension 1718
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1354 Richards Hall
fax: 617.373.8735
360 Huntington Ave
sfs@northeastern.edu
Boston, MA 02115
studentfinance.northeastern.edu
2017-2018 Confirmation of Federal Tax Extension
Student's Name: ______________________________________
NU ID: _______________________
You were asked to complete this form because you informed us that you, or your parent(s), filed an IRS Form
4868, “Application for Automatic Extension of Time to File U.S. Individual Income Tax Return.” Please complete
the following for the 2015 tax year. Do not leave any areas blank.
Name(s) of individual(s) for whom the extension was filed:
1. ________________________________________
2. ________________________________________
□
□
□
□
Self-Employed?:
Yes
No
Self-Employed?:
Yes
No
Wages earned in 2015: $____________________
Wages earned in 2015: $____________________
Estimated 2015 Adjusted Gross Income (AGI) for the above individual(s): $__________________________
Estimated 2015 U.S. Income Tax paid for the above individual(s): $_________________________________
Along with this form, please submit:
A copy of the IRS’ approval of an extension (IRS Form 4868)
A copy of all 2015 W-2(s) for each source of employment income received for each individual
named above, if applicable
IRS Verification of Non-filing Letter for all individuals who did not file a 2015 tax return
CERTIFICATION
By signing this form, I certify that I filed an IRS Form 4868, “Application for Automatic Extension of Time to
File U.S. Individual Income Tax Return” and that all of the information reported on this form is complete and
accurate.
Name (please print): ___________________________________________
Signature: ________________________________________________
Date: ___________________
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