Tusculum College

Student Support Services

Income Verification Form

Name: ________________________________________________________

Address:_______________________________________________________

_______________________________________________________

This form is to verify that a Federal Income Tax Form was not filed for ________(year).

Non-taxable income received (Please check all types received):

______Social Security

______Unemployment

______Disability

______AFDC

______Veterans Benefits

______Child Support

______Other (please list):__________________________________________

I understand that the above information will be held in strictest confidence and used to determine my student’s eligibility for participation in Tusculum College Student Support Services. I also certify that all the above information and income data is complete and correct to the best of my knowledge.*

___________________________________________________ ______________________
Signature of Parent or Guardian Date

Notarize below:

State of _______________________

County of _____________________

On this, the________day of __________, 20____, before me a notary public, the undersigned officer, personally appeared________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained.

In witness hereof, I hereunto set my hand and official seal.

                                                                      _________________________________________________

Notary Public Expires

*This form must be notarized.