2016-2017 Dependent Appeal for Special Financial Consideration
Student’s Name:______Student ID#:______
If your family’s2016 income has been reduced, you should complete this from and return it toEnrollment Services for further consideration of your 2016-2017 financial assistance. If you are unable to estimate the total income your family will receive from January 1 through December 31,2016, please keep this form until you can provide an accurate estimate. The process of verification must be completed prior to any adjustment being made. Please complete this form and return it toEnrollment Services. Include supporting documentation along with the tax documents listed. Questions concerning this form can be directed toEnrollment Services.
Attach a brief written explanation regarding your circumstances to this form.
Section 1. Please review the sections below and indicate which explanations(s) apply to your family’s 2016 income and/or expenses. Please note that further documentation may be required for certain situations. Be sure to complete both sides of this form and obtain all signatures required before returning to our office.
- Death of a family memberNote: Provide a copy of the death certificate and a copy of the deceased’s 2015 federal tax return and w-2s.
Name: ______Deceased Date: ___/___/___
- Loss of Employment of student orparent (as applicable). Period of unemployment must be at least ten weeks and the individual must have worked full-time for at least 30 weeks in the prior year, but is no longer working full-time.
Name:______Type of Change:______
Date of Status Change ___/___/___Dates of unemployment period: from ___/___/___ until ___/___/___
Provide Letter from employer stating last date of employment and reason for status change.If this is not available, please provide other documentation to demonstrate loss of employment.
Complete Section II of the worksheet on reverse side of this form estimating your 2016 income and attach documentation to support your estimate.
- Reduction of Student or Parent’s income of benefits
Name:______Date of Status Change ___/___/___
Provide a list of income or benefits and amount(s) received during 2015, as well as reason for termination or reduction. Complete Section 2 of the worksheet on estimating your 2016 income and attach documentation to support your estimate.
- Separation or Divorce
Name(s):______Date of Decree or Separation: ___/___/___
Provide both parent’s 2015 federal tax return and W-2s. Please complete Section 2 of this form listing Taxed Income for the 2015 Year.
- Unusual debt or expenses- Examples include medical, dental or vision expenses that have already been incurred or that are ongoing for the current school year and are not covered by insurance or private school tuition incurred by families. Contact the Enrollment Services for the documentation that is required.
Section 2: Complete both of the sections (gross taxed and untaxed income) below with income (prior to exemptions, adjustments, or deductions) your family expects to receive from January 1 through December 31, 2016. If none, enter zeroes. Please attach documentation to support your estimated income.
2016 Gross Taxed Income / Student’s Income / Father’sIncome / Mother’s
Income
- Wages, tips, and salaries
- Severance Pay
- Pensions and annuities
- Interest and dividend income
- Business or farm income
- Capital gains
- Income received from rents after expenses paid for mortgage interest, taxes, and insurance
- Alimony, which may be received
- Unemployment compensation (state and/or SUB
- Any other taxable income
Total 2015 Gross Taxed Income / $ / $ / $
2016 Untaxed Income
- Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings). Include untaxed portion of 401 (k) and 403 (b) plans.
- Retirement or disability benefits
- Workers’ compensation
- Untaxed portion of pensions
- Living and housing allowances (excluding rent subsidies for low-income housing) for clergy, military, and others (include cash payments or cash value of benefits)
- Child support or maintenance payments that will be received for the student and ALL other children
- Veterans’ non-education benefits
- Railroad retirement benefits
- Any other untaxed income and benefits such as Black Lung Benefits, Refugee Assistance, etc.
Total 2016 Untaxed Income / $ / $ / $
All of the information provided by me or any other person on this form is true and complete to the best of my knowledge. I agree to provide proof of any information given on this form if requested by the Enrollment Services.
Student Signature ______Parent Signature ______
Date Signed ______