DALLAS COUNTY COMMUNITY COLLEGE DISTRICT Special Circumstance Application

Transcription

1 Special Circumstance Application Scanning Doc Category: Grants Doc Type: Special Cond. Award Year: 2017 The purpose of this form is to determine the outcome of a proposed special situation. Turning in this form does not establish approval. Once you submit the form, please allow up to two (2) weeks for a response. Incomplete packets w ill result in a delay of a decision and can possibly result in denial of the request. The semester deadline date for submission of this form is two weeks prior to the end of a semester. To secure your class schedule, you must ensure your tuition is paid in full and be enrolled in a minimum of six (6) credit hours. SECTION I: Student Information CPS Selected for Verification Yes or No // Completed? Yes or No Last Name First Name M.I. Student ID # Address City State ZIP Code Primary Contact # SECTION II: Student Reason. Write a detailed explanation and attach supporting documentation. If you are unsure of the appropriate documentation, please contact the Financial Aid Office. (Multiple tax years may apply.) Loss of Employment or Drastic Change in Income: A student/spouse/parent who earned money in lost his/her job for at least 10 w eeks in OR his/her income has changed drastically from the income. You must provide documentation of loss of employment and/or drastic change in income. The follow ing items could be presented, but additional documentation may be required. Student/spouse s or student/parent (s) final or last pay stub in from all employers. The pay stub(s) must document year-to-date earnings. (Example: paycheck stub, W-2, 1099, etc.) Initial letter from Texas Workforce Commission that includes beginning and ending dates of unemployment benefits and the amount received. Official evidence of job loss. Documentation of reduction in w ork and/or work hours. For untaxed income loss (Social Security, child support, etc.), submit verifying documentation. Loss of Income due to Divorce or Separation: Since applying for financial aid, you/your parents have become divorced or separated. You must provide documentation of divorce or separation. The follow ing items could be presented, but additional Copy of the divorce decree or the divorce petition verifying separation. Signed copy of both parents federal income tax transcript (if filed separately) and ALL W-2s. Loss of Income due to Death of Spouse/Parent(s): Since applying for financial aid, your spouse/parent has passed aw ay. You must provide documentation of death. The follow ing items could be presented, but additional Copy of death certificate. Loss of Income due to Disability: Since applying for financial aid, you or your parent(s) are experiencing reduced or loss of income due to a disability. The follow ing items could be presented, but additional Disability certification. Evidence of loss of earnings (such as a signed letter from employer on company letterhead).

2 Special Circumstance Application, Page 2 Unusually High Medical or Dental Expenses: Since applying for financial aid, you or your parent(s) are experiencing unusually high medical or dental expenses (adjustments are on assets only). The follow ing items could be presented, but additional Copy of receipts for medical payments not covered by insurance from January through December. Statements must show name of patient(s), dates of charges and amount paid by patient. The federal formula used to calculate an EFC allow s for 11% of a family s adjusted gross income to be allocated to medical expenses. Only medical expenses in excess of the 11% may be considered. Medical expenses that were an itemized deduction on the federal tax transcript cannot be considered for professional judgment purposes. Previous Year One-time Increase in Income Amount: You or your parent(s) received an inheritance, lump sum Social Security payment, a retirement or IRA distribution, or some other nonrecurring payment that is not available for the current school year. The follow ing items could be presented, but additional Official documentation that identifies source of income (legal forms, financial statements, etc.). Documentation of how the funds were spent or invested and w hy they are not available as a resource. Elementary or Secondary School Tuition for Students, Siblings or Dependents: You or your parent(s) paid private school tuition for a student, sibling or dependent. The follow ing items could be presented, but additional Proof of institutional tuition expenses. Dependency Override: You may be required to meet w ith the college financial aid director by appointment for this special case situation. The follow ing items are necessary, but additional You must provide a statement describing your present situation, the reason for your request of a dependency status change for your federal financial aid application and how you supported yourself after independence from your parents. This statement must be typed, signed by you and attached to this form. You must also obtain three references by someone other than a family member or friend (teacher, counselor, medical authority, member of the clergy, prison administrator, government agency or court) that outline the same information as listed above, as w ell as the follow ing: the relationship and length of time of the relationship betw een you and the reference, the reference s phone number and address, and your current living situation. The reference statements must be typed, signed by the reference, notarized and attached to this form. The following situations DO NOT qualify for a dependency override: Parents refuse to contribute to the student s education. Parents are unw illing to provide information on the FAFSA or for verification. Parents do not claim the student as a dependent for income tax purposes. Student demonstrates total self-sufficiency. Parent Information: Father s name: Father s address: Date of last contact: Date you last received support: Mother s name: Mother s address: Date of last contact: Date you last received support:

3 Special Circumstance Application, Page 3 SECTION III: Verification Student s Family Information: List below the people in your household (or parent s household if dependent student). Include the name of the college for any household member w ho will be enrolled at least half time in a degree, diploma or certificate program at a postsecondary educational institution any time betw een July 1,, and June 30,. If you are a dependent student, do not include college information for your parents. Full Name Age Relationship College Will Be Enrolled at Least Half Time (Yes or No) Marty Jones (example) 28 Wife Central University Yes Independent Student s Family Information include: Yourself. Your spouse, if you are married. Your children, if any, if you w ill provide more than half of their support from July 1,, through June 30,, or if the child w ould be required to provide your information if they w ere completing a FAFSA for (Include children w ho meet either of these standards, even if they do not live w ith you.) Other people if they now live w ith you and you provide more than half of their support and w ill continue to provide more than half of their support through June 30,. Dependent Student s Family Information include: You and your parent(s) (including a stepparent), even if you don t live w ith your parent(s). Your parent(s) other children if your parent(s) will provide more than half of their support from July 1,, through June 30,, or if the other children w ould be required to provide parental information if they w ere completing a FAFSA for -. (Include children w ho meet either of these standards, even if they do not live w ith your parent(s).) Other people if they now live w ith your parent(s) and your parent(s) provide more than half of their support and w ill continue to provide more than half of their support through June 30,.

4 Special Circumstance Application, Page 4 SECTION IV: Student / Family Income (Must Complete) Complete the following table. Do not leave any areas blank: If a field does not apply to you, write N/A ; if you did not receive any amount, write 0. If you are submitting this form after Dec. 31,, you may be required to submit a copy of your completed federal tax transcript, tax schedules and W-2s Income from work (wages, salaries, tips, net business/farm income) Unemployment compensation, dividends, interest, pensions, capital gains, other Student / Spouse Father / Mother Student / Spouse (include projections) Social Security benefits Child support received Workers compensation AFDC/TANF (welfare benefits) Veteran s noneducational benefits Untaxed pensions, taxdeferred pensions, IRAs Father / Mother (include projections) 9 10 Military housing, food or living allowances Cash or money paid on your behalf TOTAL INCOME (add items 1-10) TOTAL FAMILY INCOME: (add lines for ) (add lines for ) : : SECTION V: Signature Requirements I certify, by signing below, that all of the information on this form is true and complete to the best of my know ledge. Student Signature Date Spouse Signature Date Parent 1 Signature Date Parent 2 Signature Date

5 Special Circumstance Application, Page 5 SECTION VI: Review Statement (For Office Use Only) Statement: Total Family Income (minus) total Family Income = Difference Difference in Income: (divided by) Total Family Income = Percentage Difference % Approved Notice Sent Notes recorded in FAMS Denied Notice Sent Notes recorded in FAMS Will not benefit Notice Sent Notes recorded in FAMS Applicable Notes: Authorized Signature: Date: Financial Aid, College Director The seven independently accredited colleges of the Dallas County Community College District are part of an equal opportunity system that provides education and employment opportunities without discrimination on the basis of race, color, religion, national origin, sex, disability, age, sexual orientation, gender identity or gender expression. Revised 04/12/17