Non-Tax Filer Statement 2021

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Student's Name

SSN

Address

Income information provided is for

Student Parent

Please list all sources of taxable income for 2021.

Taxable Income 2021
#	Employer/Source	Amount Earned
1
2
3
4

Total Taxable Income

Please list all sources of untaxed income for 2021. For students, if your parents are divorced, please include any amount paid to you or for you (e.g. tuition payments) by your non-custodial parent.

Non-Taxable Income 2021
#	Employer/Source	Amount Earned
1
2
3
4

Total Non-Taxable Income

I, NAME, have not filed and will not file a 2021 U.S. Income Tax Return.