Certification Of Unfiled Tax Returns

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CCS - College for Creative Studies
2012-2013
CERTIFICATION OF UNFILED TAX RETURNS
This form is only to be completed in the event that a student, parent, or student’s spouse did not file a federal tax return
for 2011. If you did file a return please provide us with a copy in place of this form.
Student’s Name _______________________________________________________SS#__________________________
The following statements are to be completed by (i.e. who did not file taxes):
_____ Student (You must sign before a Notary Public; parent’s signature is not required)
_____ Student and spouse (Both student & spouse must sign before a Notary Public)
_____ Parent of student (Both student and parent must sign before a Notary Public)
PLEASE CHOOSE ONE OF THE FOLLOWING
I (we) did not and will not file a Federal Income Tax Return (IRS Form 1040, 1040A, or 1040EZ) for 2010. I (we) will, if
requested, provide official documentation from the Internal Revenue Service (IRS) to this effect. The reason for not filing a
Federal Income Tax Return was:
_____ I (we) received no taxable and/or untaxable income for tax year 2011.
_____ I (we) received taxable and/or untaxable income, however, taxable and/or untaxable income received was
less than the amount required for filing a tax return. My (our) total income (taxable and/or untaxable) for
2011 was $_____________ from the following sources (if earned from a job, please provide a W2):
MUST BE SIGNED BEFORE A NOTARY PUBLIC
I (we) hereby swear or affirm that the information reported on this form and any attachment hereto is true, complete and accurate
to the best of my (our) knowledge. I (we) understand that any false statement or misrepresentation will be cause for denial,
reduction, withdrawal, and/or repayment of financial aid, and may subject the filer(s) to a fine or imprisonment, or both, under
provision of the U.S. Criminal Code.
________________________________________________
________________________________________________
Signature (student)
Signature (parent or spouse)
________________________________________________
________________________________________________
Name (please print)
Name (please print)
________________________________________________
________________________________________________
Date
Date
City/County of ____________________ State of ___________________ sworn to and subscribed before me this
_____________day of ___________ 2012, witness my hand and official seal.
________________________________________________
_________________________________________________
Signature of Notary Public
Date Commission Expires
(please place seal here)

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