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

TRiO STUDENT SUPPORT SERVICES- STEM

DEPENDENT

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 family income was filed with the Internal Revenue Service for the previous tax year(s) 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 a dependent student and my parent(s) TOTAL INCOME from all sources in the year(s) 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 your family was supported on this income.

Total number of exemptions in household:*

(Please indicate the number of dependents your parent/guardian has, including yourself. **Note: You should have at least 2 exemptions [your parent/guardian and yourself])

Student's Signature:*

Date:*

mm-dd-yyyy

Parent's Signature:*

Date:*

mm-dd-yyyy

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

Explanation:*