Special Circumstance Form

Transcription

1 ID# Phone # NDSU Have you submitted a Special Circumstance Form to NDSU in any previous year? Special Circumstance Form If you are completing this form you are requesting that financial aid award be re-evaluated because of a special circumstance which impacts your/your parent(s) ability to contribute toward your educational expenses. The submission of this form does not guarantee a favorable change in your financial aid award. All students who are eligible for a special circumstance revision will be required to complete verification. Once verification is complete your special circumstance revision will be completed. This may take up to 4 weeks. The results of your special circumstance revision will be sent to your NDSU address. Submit this completed and signed form and all supporting documentation listed for your specific special circumstance category to: NDSU One Stop NDSU Dept PO Box 6050 Fargo, ND Fax: (701) Scan and to ndsu.onestop@ndsu.edu Drop off location: 176 Memorial Union (NDSU One Stop) I certify the information on this form is true and accurate to the best of my knowledge. I understand that purposely giving false or misleading information will result in denial of my request and I may be subject to, fines, penalties, and/or reduction or immediate repayment of aid, and referral to Affairs for a code of conduct violation. I understand that the information provided on this form may affect my/my student s financial aid eligibility/award. Signature Date Note: Unsigned documents will be returned. This form must be signed with a physical signature. Typed names or electronic signatures are not acceptable. Parent Signature (if parental information is provided) Date Note: Unsigned documents will be returned. This form must be signed with a physical signature. Typed names or electronic signatures are not acceptable. HOUSEHOLD INFORMATION Include all members of your household in the chart below. Dependent s - include yourself, your parent(s), and any dependents for which your parent(s) provide more than half of their support. Independent s - include yourself, your spouse, and your dependent children. Date of Birth College/University Attending in NDSU If more space is required, attach a separate page. Page 1

2 INSTRUCTIONS - Identify your special circumstance(s) by checking (X) each category that pertains to you. Answer all questions in selected categories and attach any additional information required. NOTE: If you have requested review in more than one category, be sure to include the required documentation for each category. Forms with incomplete documentation will not be processed. LOSS OR REDUCTION OF INCOME Select this category if your 2018 projected income (January 2018 December 2018) will be less than the 2016 income reported on the FAFSA. Complete ALL columns in the chart below. This category can only be used if the reduction of income occurred before November 1, If the loss of income is for one parent, but your parent s combined 2018 earnings will exceed their 2016 earnings, do NOT complete this section. 1. A copy of the most recent pay stub showing 2018 year-to-date earnings for the person with the loss/reduction of income 2. A copy of the termination, lay-off notice or final pay stub, if you have one. 3. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted your/your INCOME LOSS/REDUCTION AND PROJECTED INCOME Did this family member have a reduction/loss of income? If no, skip to lower section. Date Income was Reduced/Terminated Reason for Reduction/Loss of Income (Example: terminated, seasonal lay-off, attending college, etc.) Father/ Step-Father Mother/ Step-Mother Complete the section below to project 2018 calendar year income (January 2018 December 2018) for all columns. Estimate the figures to the best of your ability. Do not leave anything blank; if the amount is $0, enter $ GROSS (not net) earnings from work $ $ $ $ 2018 Unemployment benefits $ $ $ $ 2018 Child Support Received $ $ $ $ Other (List Income Type) (Example: worker s comp, private disability, alimony, etc.) $ $ $ $ Spouse of SEPARATION OR DIVORCE OF PARENTS Select this category if your parent(s) were married when you completed the FAFSA but are now separated with the intent to divorce or are divorced. Complete the chart below. s Do NOT use this form to update your marital status. If you have a marital status update, please call Mary at for assistance. 1. Copy of parents divorce judgement and decree or a letter from an attorney stating legal proceedings have begun. SEPARATION OR DIVORCE OF PARENTS Date of Parents Separation/Divorce Which parent provides the majority of your support? Page 2

3 LOSS OR REDUCTION OF BENEFITS (CHILD SUPPORT, UNEMPLOYMENT, ALIMONY, PRIVATE DISABILITY) Select this category if you, your spouse or parent(s) received benefits in 2016 that will not be available in Complete the chart below. Do NOT include the following: Social Security Benefits (SSI or SSDI), medical or other benefits received with an employment package. 1. Copy of a letter/documentation from court or other agency verifying the date of the reduction or termination of the benefit. BENEFIT LOSS Type of Benefit (Example: child support, unemployment, alimony, etc.) Date Benefit was Reduced/Terminated Reason for Reduction/Loss of Benefit (Example: benefit terminated, court ordered change, etc.) 2016 Total Amount of Benefit Received (Jan. Dec.) $ $ 2018 Total Amount of Benefit Expected (Jan. Dec.) $ $ OUT-OF-POCKET PAYMENTS FOR MEDICAL/DENTAL/VISION and HEALTH INSURANCE PREMIUMS Select this category if you, your spouse or parent(s) paid 2017 medical/dental/vision expenses or health insurance premiums in excess of 7.5% of your 2016 Adjusted Gross Income. Complete the chart below. Bills will only be considered if they were incurred and paid in 2017 and were NOT covered by insurance. Adjustments will not be made for medical expenses until after January 1, Proof of payment (see examples of acceptable documentation below) a. If you/your parent(s) itemized deductions on the 2017 tax return, a copy of Schedule A must be submitted with this form. If you will be itemizing your taxes, submit this form after the 2017 taxes are filed. b. If you/your parent(s) paid health insurance premiums in 2017 that were NOT included on Line 1 of Schedule A or did not itemize your taxes, submit a copy of the 2017 premium statement, a letter from the insurance company stating the total amount paid in 2017, or your final 2017 pay stub showing the total premium amount that was deducted from the paycheck. c. If you/your parent(s) did NOT itemize and took the standard deduction, submit a letter from each provider indicating the total amount paid out of pocket in 2017 for medical/dental/vision expenses. MEDICAL/DENTAL/VISION EXPENSES OR PREMIUMS 2017 Total Expenses Paid (not covered or reimbursed by insurance) $ 2017 Total Health Insurance Premiums Paid $ Page 3

4 UNUSUAL DEBT OR EXPENSE Select this category if you, your spouse or parent(s) had an unusual debt or expense in 2016 that was unavoidable and will negatively impact the ability to pay for educational expenses. Complete the chart below. Only paid expenses will be considered. Expenses that may be considered include: dual housing costs necessitated by economic conditions, funeral expenses not covered by life insurance, natural disaster expenses not covered by insurance, FEMA or other agency, special travel/lodging for medical reasons, etc. Expenses that cannot be considered include: vacations, weddings, standard living expenses, home renovations, credit card debt, auto loans/insurance, auto repairs, expenses related to self-employment, etc. 1. Description of debt or expense 2. For Natural Disaster Documentation of completion of repair and final total cost. A letter from FEMA and insurance agency indicating amount they will cover. Proof of payment to cover remaining cost of repair. 3. For Dual Housing Costs Copies of lease showing amount paid for rent and names of renters and heat/electric/water bill. Lease or mortgage statement from primary residence. 4. For Other Unavoidable Expenses Copies of bills, receipts or other documentation that verifies the debt or expense. 5. For Elementary/Secondary Private School Tuition - Copy of the 2017 tuition bill(s) from the private school(s) attended or letter from school with the total cost. Documentation from a physician, counselor, or school official detailing the specific needs of the student attending private school and confirming that it is not possible for the student to receive needed services or accommodations in a public school setting. You must also: Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted your/your UNUSUAL DEBT OR EXPENSE Type of Debt/Expense (Example: funeral expense, dual housing, etc.) Amount of Debt/Expense $ $ DEATH OF PARENT OR SPOUSE Select this category if your parent(s) or spouse passed away after your FAFSA was filed. Complete the chart below. If their funeral expenses were not covered by life insurance, you may also wish to complete the Unusual Debt or Expense category above. 1. Copy of death certificate, obituary or memorial program. DEATH OF PARENT/SPOUSE of Deceased Date of Death Page 4

5 ROTH IRA Select this category if you/your parent(s) or spouse converted a regular IRA to a Roth IRA by transferring funds and the amount converted was reported as taxable income on you/your parent(s) 2016 federal income tax return. Submit the following additional required documentation: 1. Copy of Form 8606 (Nondeductible IRA) for the 2016 tax year for the person with the Roth IRA. ADDITIONAL INCOME IN 2016 USED TO PAY OFF DEBT Select this category if you, your parent(s) had additional income in 2016 that was used to pay off debt, to avoid bankruptcy, foreclosure, referral to collections, or other extreme financial hardship (including payment of standard living costs following a loss of income), and that income was reported as a capital gain on your 2016 taxes. Complete the chart below. 1. Written statement outlining how funds were spent (bills paid and amounts). 2. Documents from lenders/creditors showing the amount of debt that was paid and the date it was paid. a. If the outstanding debt was paid prior to referral to collections, submit a letter from the agency stating the account/bill was past due. b. If assets were liquidated to pay standard household expenses due to lost or reduced income include a list of specific costs covered and documentation of the reason for the lost or reduced income. 3. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted your/your ADDITIONAL INCOME 2016 Source of Income Amount Received Page 5