Professional Judgment Income Reduction and Fax Coversheet

Transcription

1 Student Legal Last Name (print or type) First Name Middle Initial Student IRN In limited circumstances, the University may independently modify student financial aid eligibility using (PJ) to evaluate unusual circumstances on a case-by-case basis only, in accordance with U.S. Department of Education regulations. Unusual circumstances shall be conditions that differentiate an individual student from a class of students rather than conditions that typically exist across the class of students. To request a professional judgment review, submit this form with appropriate documentation as outlined in this form. : You may request a PJ review to address instances when the 2014 income reported on your FAFSA, does not accurately reflect your or your family s ability to pay for education. Possible examples of special circumstances include change or loss of employment, disability, divorce and/or separation, death, or receipt of non-recurring income. Answer all of the following questions. Note: Parent(s) information is required for Dependent students only. 1) Indicate the individual(s) who recently had an income reduction: Student Spouse Parent(s) 2) What is the date you or your spouse/parent(s) income was reduced or lost? / (mm/yyyy) 3) Are you or your spouse/parent(s) entitled to collect unemployment benefits? Yes No 4) Do you currently earn income to pay for food, shelter, and personal expenses? Yes No 5) If your income reduction is the result of a change in marital status after the date the FAFSA was signed, what was the date of the marital status change? / (mm/yyyy) 6) If your income reduction is the result of the death of your spouse or parent(s), what was the date of the death? / (mm/yyyy) Page 1 of 6

2 Household Members Table: Please review your FAFSA. If the information on your FAFSA has changed, complete the table below reporting all household members who receive more than 50% of student/spouse/parent(s) support (including any child support paid or received). Household Members Household Members (names of ALL members) Age Relationship to Student College/University Name (if attending at least half-time) Child Support (indicate paid or received) Example: Mary Smith 8 Daughter N/A 300/mo Received Income Table: Indicate your and your spouse s/parent(s) projected monthly income and gross year-to-date earnings based on your current situation. If a household member is self-employed and does not receive pay stubs as a result of being self-employed, income must be reported on the Income Table. All recurring income must be reported. Further, those that are self-employed should also submit a quarterly earnings report, a profit and loss statement, and/or form 1099-MISC. Income Table Household Members Student, Spouse, Parent(s) (if Dependent) Source of Income (Employer, SSA, Workers' Comp, Unemployment, Disability, Pension, etc.) Projected Monthly Income Year-to-Date Income Alimony Received Example: Spouse ABC Company 1,000 15,000 N/A Page 2 of 6

3 Estimated Monthly Expenses Table: If you answered No to Question 4 on page 1 and/or reported 0 income on the Income Table, estimate your expenses to the best of your ability. If a line item is zero, enter 0. Estimated Monthly Expenses Rent/Mortgage Utilities (electric, phone, water, etc.) Clothing and Personal Care Miscellaneous (entertainment, etc.) Car (insurance, maintenance, etc.) Transportation Costs Groceries Child Care Medical Expenses Other (credit card, etc.) Total Estimated Monthly Expenses = 0 Income Reported: If you answered No to Question 4 on page 1 and/or reported 0 income on the Income Table, you must assign a monetary value to the amount of support you receive. Please indicate an approximate amount of money paid on your behalf to cover your personal needs and expenses. 0 Income Reported Approximate Amount Paid on your Behalf Daily Weekly Monthly Note: If your monthly expenses exceed the amount paid on your behalf, you must explain in the space below how the difference is paid. Explain how monthly expenses are paid. Itemize using any income and assets you have. If you have someone assisting with expenses, please list that information. This list should include any financial support, such as official and unofficial child support, odd jobs, parental support, or financial assistance you receive. Page 3 of 6

4 Explain your loss or reduction of income in the space below. Please include employment history (employer name, start date, and end date) from January 1, 2014 to current date for student, spouse (if married), and parent(s) (if Dependent). Student Employment History: Spouse or Parent(s) Employment History: Untaxed Income: If you or your parent(s) entered an amount on the FAFSA indicating 2014 Untaxed Income received (45a-j or 95a-i), please complete the table below if any information has changed from what was originally reported. Updates to these fields will only be made if applicable documentation to support the change(s) is provided. Untaxed Income Non-Income Student / Spouse Payments to tax-deferred pensions and savings IRA deductible payments to self-employed SEP, SIMPLE, Keogh, other Child support received Tax exempt interest income Untaxed portions of IRA distributions Parent(s) Non-Income Student / Spouse Untaxed portions of pensions Housing, food, and other living allowances paid to military or clergy members Veterans noneducation benefits Other untaxed income or benefits Money received or paid on behalf of student Parent(s) Page 4 of 6

5 Required Documentation: Please submit the following documentation based on your circumstance(s). A. Loss of Income Due to Job Loss / Reduction of Hours / Receipt of Non-Recurring Income Final pay stub(s) from previous employer(s) and most recent pay stub(s) from current employer(s) Pay stub(s) must include gross year-to-date (YTD) earnings and pay period dates Supporting documentation confirming your income reduction/loss Employer separation letter (if job loss was within the last 30 days) Unaltered unemployment paperwork dated within 90 days Documentation of non-recurring income (i.e., IRA Distributions, 1099-Rs, Rollovers, etc.) W2s/1099s for student, spouse, and parent(s) (if Dependent) B. Loss of Income Due to Change in Marital Status after Date FAFSA was Signed Copy of divorce decree or separation agreement (if there is no legal separation agreement, please confirm date of separation in Question 5) Final pay stub(s) from previous employer(s) and most recent pay stub(s) from current employer(s) Pay stubs must include gross year-to-date (YTD) earnings and pay period dates W2s/1099s for student and parent(s) (if Dependent) Report any alimony and/or child support received/paid on the applicable tables above Report all household members who are supported by student/spouse/parent more than 50% on the Household Members Table C. Loss of Income Due to Death of Spouse or Parent(s) (if Dependent) Photocopy of death certificate, obituary, or funeral announcement Documentation confirming benefits being received (i.e., survivor benefits, life insurance, etc.) Final pay stub(s) from previous employer(s) and most recent pay stub(s) from current employer(s) Pay stubs must include gross year-to-date (YTD) earnings and pay period dates Note: The University may request additional information to support your unusual circumstance after the request form is received. CERTIFICATION STATEMENT I certify that the submitted information is true and correct to the best of my knowledge and belief. I have read each section and have provided the required documentation. I acknowledge by signing below that my request may not be processed if I do not provide the required supporting documentation. Student Signature Date Fax this form, using the attached coversheet, along with supporting documentation to Student Financial Services Operations at (877) Page 5 of 6

6 Fax Coversheet Student Financial Services - Operations Fax: (877) Student Name: Date: Student IRN: Number of Pages (including coversheet): Please indicate the supporting documentation you are including with the coversheet: *All statements must be signed and dated* PJ request form (all pages must be fully completed) Student statement Must address employment history Unemployment benefits letter Must be dated within the last 90 days Must confirm approval/denial/disqualification of benefits Payment history and/or slips may also be submitted Recent Pay Stub(s) Must clearly show gross year-to-date earnings and pay period dates Other, please specify: Page 6 of 6