Tax Certification - David Geffen School Of Medicine At Ucla printable pdf download

Financial Aid and Scholarships

17-253 West, Center for the Health Sciences

Box 957020

Los Angeles, CA 90095-7020

Office: (310) 825-4181

Fax: (310) 794-1629

Email: fao@mednet.ucla.edu

2016‐2017 TAX CERTIFICATION

Print, complete, and sign this form.

Continuing students: Turn in to 17-253 West, CHS by the

deadline of April 22, 2016

Students who want to be considered for need-based financial aid from the David Geffen School of Medicine at UCLA,

must provide parent and student tax information in addition to completing the Free Application for Federal Student Aid

(FAFSA) and the Need Access Application. We cannot determine your eligibility for need based aid, until you submit all



required documents.

Last 4 Digits of SSN:

XXX – XX - __________________

SID: _________________________________

Last Name:

_____________________________

First Name: ___________________________

Program:

_____________________________

Class:

___________________________

Parent Tax Form and Income Information (check one)





I/we have attached a complete and signed copy of our 2015 Federal tax return (IRS Form 1040/1040A/1040EZ).

Schedules are not required.



I/we will not file and are not required to file a 2015 Federal tax return (IRS Form 1040/1040A/1040EZ).Please

complete and submit the Parents’ Statement of Expenses and Resources form.

Student Tax Form and Income Information (check one)





I have attached a complete and signed copy of my (and spouse, if married) 2015 Federal tax return

(IRS Form 1040/1040A/1040EZ). Schedules are not required.



I will not file and am not required to file a 2015 Federal tax return (IRS Form

1040/1040A/1040EZ).



If you are a non-filer and received any income from an employer,

please attach a copy of a W-2 Form for

each source of employment received in

2015.



If a W-2 Form is not available, you must explain below the reason, as well as the amount and source of the

income. An example of income with no W-2 is a STTP Stipend.

_________________________________________________________________________________________

We, the undersigned, fully recognize that any false or misleading information given to establish eligibility for Federal stu-

dent aid may lead to a fine, a prison sentence, or both. In addition, misleading or dishonest representations in financial aid

application materials will be cause for disciplinary action of the student, which may include dismissal from medical school.

___________________________________ _________

Student Signature

Date

Spouse (if married) Signature

Date

___________________________________ _________

Father/Step-Father Signature

Date

Mother/Step-Mother Signature

Date

Tax Certification - David Geffen School Of Medicine At Ucla

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