Passaic County Community College-STEM-SSS-Independent Verification Form

TRiO STUDENT SUPPORT SERVICES - STEM

INDEPENDENT

Income Verification Form

Student Name:*

First NameLast Name

Email:*

example@example.com

ID:*

In accordance with the TRiO/SSS eligibility requirements set forth by the United States Department of Education, I hereby certify that NO Federal or State tax return documenting my income was filed with the Internal Revenue Service for the previous tax year of*

(Please input the year number for the previous tax year. For example, input "2021" if that was the previous tax year)

I CERTIFY THAT I am an independent student and my TOTAL INCOME from all sources in the year of *

(Please input the same year number from above)

was $*

(In numbers, please input the amount of income that was earned in the indicated year)

Note: If income is exceptionally low or income taxes were not filed, please explain on the bottom of this page, how you supported yourself and/or your family on this income.

Total number of exemptions in household: *

(Please indicate the number of people, including yourself, in your family if married or if you have dependents. **Note: You should have at least 1 exemption [yourself]).

Student's Signature:*

Date:*

mm-dd-yyyy

By signing this document, I attest under penalty of perjury that the above statement is true and correct.

Explanation:*