Office Tracking Code: TXS11

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2012-13 Academic Year 2011 Student Income Tax Return Non-Filers Statement
Student Name: LIN:

Complete this from if you are not required to file a 2011 Federal Income Tax Return. Enter below the amount(s) received in 2011 from each income source. Do not leave any field blank. Indicate $0 if you did not receive any income from the specified source. Also, attach a copy of all W-2's from employer(s) for wages earned in 2011, or explain where you worked and why you are not providing documentation. Income earned from work: Income earned from work: Interest earned (cash, savings and checking account(s)): Dividends: Other taxable income (alimony, pensions, annuity, unemployment, etc.): Aid to Families with Dependent Children (AFDC): Other untaxed income (welfare benefits, Veteran's benefits, worker's compensation, untaxed social security, etc.):** TOTAL INCOME
** Explain the source(s) of other untaxed income and benefits reported: Student Spouse

$ $ $ $ $ $ $ $

ADDITIONAL COMMENTS:

I (We) certify that I(we) have not and will not file a 2011 Federal Income Tax Return, and officially state that all the information listed above is accurate to the best of my (our) knowledge. Student Signature: Spouses Signature (If Applicable): Date: ***Remember to attach copies of any W-2 forms*** Please submit to Lehigh Universitys Office of Financial Aid Via Fax: (610) 758-6211, Dropbox via www.lehigh.edu/financialaid, or Email: financialaid@lehigh.edu