Financial Aid Office
1200 16th Street
Golden CO 80401
303-384-2252 fax

Verification of 2015 Income Information for Parent Nontax Filers

Student: ____________________________________ Campus Wide I.D.#:____________________

The instructions and certifications below apply to each parent included in the household. Complete this section
if the parent(s) will not file and are not required to file a 2015 income tax return with the IRS.

Check the box that applies:

Neither parent was employed and had no income earned from work in 2015.

One or both parents were employed in 2015 and have listed below the names of all employers, the
amount earned from each employer in 2015, and whether an IRS W-2 form is provided. It is required to
provide copies of all 2015 IRS W-2 forms issued to the parent(s) by their employers. List every
employer even if the employer did not issue an IRS W-2 form. Please submit the form once all W-2s
have been collected and the form has been completed.

If more space is needed, provide a separate page with the student’s name and ID number at the top.

Employer’s Name
2015 Amount
IRS W-2 Provided? If not, please explain.
Al’s Auto Body Shop (example)

By signing below, I(we) certify that all the information reported on this worksheet is complete and correct.
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined,
be sentenced to jail, or both.

Parent ____________________________________