Zero Income Verification Form - 2015-2016
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1SOUTHERN UNVERSITY AND A&M COLLEGE
Office of Student Financial Aid
2015-2016:
ZERO INCOME VERIFICATION FORM
According To the Federal Processing Center, you reported zero ($0) income for yourself and/or family member on
your Free Application for Federal Student Aid (FAFSA). In order to continue the verification process of your file,
you and/or your family member must complete and return this form to the Southern University Baton Rouge Office
of Student Financial Aid.
Student: ____________________________________ Student SSN or SID#:_______________
Please provide information pertaining to the person(s) reporting zero income:
NAME
SS#
Relationship to
Year Zero Income
Student
Occurred
□
□
Did you receive any untaxed income in 2014?
Yes
No If yes, please indicate the source and amount:
Income Source
2014 Untaxed Income
2014 Untaxed Income
Student/Spouse
Parents (Dependent Students only)
Job:_______________________
Social Security Benefits
AFDC/TANF
Child Support
Food Stamps Received
Other:______________________
Cash Support Received in 2014
Amount: $ ____________________
(Cash Support is defined as money, gifts, loans, or any other expense(s) paid on your behalf such as housing, food, clothing, car payments or
other expenses such as bills, medical or dental care).
Did you and/or your parent(s) (if dependent) file a Federal IRS Income Tax Return for the 2014 tax year?
□ Yes
□ No
If yes, please submit a signed copy of your (and your parent’s, if dependent) IRS Tax Return Transcript(s).
If no, please explain in detail your circumstances and specify how your family or Parent’s family (if
dependent) was able to meet its financial obligations with zero income. Also, please submit a copy of your
and/or your family member’(s’) 2014 Wages Record File from the Louisiana Work Department of Labor
Unemployment Office (Contact Number: 1-866-783-5567) or submit a Notarized statement acknowledging
the monetary expenses received, if requested. For Additional space, you should use the reverse side or
attach an additional letter. Our office reserves the right to ask for additional documentation if your
explanation does not prove your situation.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
**Warning: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.**
**By signing this worksheet, I (we) certify that all the information reported on it is complete and correct.**
Student’s Signature: _________________________________Date: _______________________
If applicable, the following family member must sign and date:
Parent’s Signature: __________________________________Date: _______________________
Spouse’s Signature: _________________________________ Date: _______________________
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