Institutional Verification Form Page 2
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2CALENDAR TAX YEAR 2014
EPCC ID: _____________________
NON-FILERS:
Check here if the student and/or spouse did not work and will not and is not required to file a tax return.
Check here if the student and/or spouse did work and earned U.S. wages but will not and is not required to
file. List any wages earned in 2014 below.
Sources (Name of Employer)
2014 Income
Student
Spouse
ONLY FOR DEPENDENT STUDENTS
Check here if your parent(s) will not and are not required to file a tax return.
Check here if your parent(s) did work and earned U.S. wages but will not and are not required to file. List
any wages earned in 2014 below.
Sources (Name of Employer)
2014 Income
Father
Mother
CHILD SUPPORT PAID CERTIFICATION:
Check here if child support was not paid by student/spouse and/or parent(s).
Check here if child support was paid by student/spouse and/or parent(s)) and fill out chart below:
Name of Person who
Name of Person to
Name of Child for
Amount of Child
Paid Child Support in
Whom Child Support
Whom Child Support
Support Paid in 2014
2014
was Paid in 2014
was Paid in 2014
SNAP Benefit Certification: (Food Stamps)
Check here to certify that in 2013 or 2014 a family member listed in the Family Household Information
section of this form received benefits from the Supplemental Nutrition Assistance Program (SNAP).
Check here if no family member listed in the Family Household Information section of this form received
benefits from the Supplemental Nutrition Assistance Program (SNAP)
Each person signing this worksheet certifies that all the information reported on it is complete and correct.
The student and at least one parent (if dependent) must sign. WARNING: If you purposely give false or
misleading information on this worksheet, you may be fined, be sentenced to jail or both.
__________________________________
_____________
____________________________________
______________
Student signature
Date
Parent signature
Date
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Rev. 03/25/2015
"The El Paso County Community College District does not discriminate on the basis of race, color, national origin, religion, gender, age,
disability, veteran status, sexual orientation, or gender identity"
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