DocuSign Envelope ID: 75D4028D-CA03-4461-82FD-41DB75CCA74F

2023-24 Academic Year

Student's Non-tax Filer's Statement

CBFinAid ID: HAA29XB

Form ID: CBL2000497017

11/08/2022

Student Information
Applicant First Name kudupudi shyamal
Applicant Middle Name shyamal
Applicant Last Name Sri Niketh
Date of Birth 10/24/2003
CBFinAid ID HAA29XB
Email Address kudipudishaymal0123@gmail.com

Spouse Information
Spouse First Name
Spouse Last Name
Email Address
Confirm Email Address

Income Information

If you are not required to file a 2021* federal tax return, enter the information below, print and
sign, and submit with supporting documentation such as 2021* W-2 form(s), 2021* 1099 form(s),
or statements from your employer.

Please note if you are a US Citizen, your school may also request you to submit an IRS Verification of
Non-filing Letter which you can request from the IRS using form 4506-T at
https://www.irs.gov/individuals/get-transcript.

List below all of the sources and amounts of money received from January 1, 2021 through
December 31, 2021. Include all untaxed income (e.g., AFDC, SSI, military living allowance) and
earnings.

Source of Income Amount

NO INCOME 0

Total:
0

Currency* Indian rupee

*If your country's tax year does not follow the calendar year you should enter the
information requested above for your country's last tax year that ended or will end
before April 1, 2021
DocuSign Envelope ID: 75D4028D-CA03-4461-82FD-41DB75CCA74F
DocuSign Envelope ID: 75D4028D-CA03-4461-82FD-41DB75CCA74F

kudupudi shyamal Sri Niketh Signature

You will receive an email request via DocuSign to sign this document. Your application
is not complete until it is signed. Once you have signed via DocuSign please allow up to
24 hours for the document to be marked complete in your IDOC Student Portal.

By signing this document, you certify that you did not and are not required to file a 2021
U.S. federal tax return. In addition, you certify that all of the information reported on this
form is complete and correct.

kudupudi shyamal Sri Niketh Signature \s1\ 11/8/2022

Date \dt1\