Upward Bound Program

Statement of Income

Student Name: Last, First, MI *

Father Name: Last, First, MI *

Mother Name: Last, First, MI *

Legal Guardian Name: Last, First, MI

I, (Parent or Legal Guardian Name) *

of (Student Name) *

hereby state that my family's current annual taxable income is $ (add amount 1040:Line 43) *

and that the total number of people in my house is (number of people living in your house) *

Check one:

Income Tax Form

I have attached a copy of my most recent income tax form 1040, 1040A, 1040EZ. (Attach prior year income tax for of you have not yet filed for the current year.)

I have attached a letter from TANF

I do not have a copy of my 1040/1040A, or 1040EZ Income form.

I did not file a Federal Income Tax Form for the past year.

If you did not file a Federal Income Tax Form for the past year, check one item that best describes why:

I received no taxable income. (If this is checked, please submit W-2 forms for the past year, and/or a Notarized statement of past year's income)

Taxable income received was less than the amount required for filing a tax return. (If this is checked please submit W-2 forms for the past year, and/or a notarized statement of past year's income).

Other:

Explain:

W-2 and/or notarized statement.

My total income (money that you earned for the past year) was $ (add amount from 1040:Line 22) *

from the following sources: ( list sources)

Last year, I received nontaxable income from the following sources (please submit copy(s):

Social Security Benefits: (Please add amount per month and how many months you received it last year)

Disability Benefits: (Please add amount per month and how many months you received it last year)

TANF: (Please add amount per month and how many months you received it last year)

SoOther: (Please list from where, add amount per month and how many months you received it last year)

I hereby affirm that the information reported on this form and any attachments hereto is true, correct, and accurate to the best of my knowledge.

Parent/Guardian Signature *

Signature Type: SMS Start Over

After validation, the cell phone number will become part of the electronic signature.

Cell Phone Number:

Enter characters above to send message.

Date: *