Upward Bound Math and Science Program Income Statement

Income verification is required in order for a new student applicant to be considered for admission. Income tax returns (Form 1040A, pages 1 and 2), showing the student applicant as a dependent on the tax return, as well as the families taxable income, is preferred. However, for those families who did not file taxes, this form must be completed and signed by the parent or legal guardian who cares for and supports the student applying to the Upward Bound Math and Science Program.

Student First Name

Student Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to student

Household size:

Address

Country

Street

City

Region

Postal Code

I herby certify that the above student resides with me at the address listed; that I provide financial support to the above named student; and that I do not (or did not) file income taxes.

Confirm

I agree to the above statement

Please list below ALL sources of income (wages, social security, disability, child support, etc.), the amount of income you receive from that source, and specify how often you receive that income. If you chose “Other” under frequency, please explain how often you receive that source of income.

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Source of Income
Source of Income Amount of Income Frequency Other, please explain:

Click here for additional spaces if you have more sources of income

Signature of Parent/Legal Guardian

Date