Special Circumstances Review Application - South Piedmont ...

Special CircumstanceReview Application2013-14 Academic YearNOTE: If you are a dependent student, the special circumstance can only apply to your parents.Print Name: _______________________________________ Student ID: ______________________Address: _________________________________________City, State, Zip Code: ________________________________Phone Number: __________________E-mail: _________________________Please include an explanation of the special circumstances that you and/or your spouse or parents havethat may affect your eligibility for financial aid. (Space provided on last page of application)I (We) certify that the information/documentation given with this Special Circumstance Review Application iscorrect. If this application indicates adjustments can be made, I authorize the Office of Financial Aid and VeteransAffairs to make these changes electronically on my behalf.WARNING: Any person who makes false statements or misrepresentations on this form may be subject toa fine or imprisonment or both, under provisions of the United States Criminal Code.____________________________________________________________Student Signature____________________________________________________________Parent Signature(Must be signed by a parent if parent(s) income is reported on the FAFSA)_______________Date_______________DatePlease check the categories that apply to your request. Provide all of the required documentation based on thecategories you have checked.A. Change in employment status from 2012B. Separation/DivorceC. Death of Spouse / ParentD. Loss of Income or BenefitsE. Received one-time income in 2012F. Other Conditions/Changes in Income—provide a detailed explanationReturn completed form to:South Piedmont Community College, Office of Financial AidLLP Fax: 704-272-5303 OCH Fax: 704-993-2425E-Mail: finaid@spcc.edu

Student Name:_________________________________Student ID: ________________A. Unemployed or employment status has changed from full-time to part-time OR change in employment statusdue to retirement. Student Spouse ParentDocuments Required:1. A letter from previous employer on company letterhead stating:• Last date of employment• 2013 earnings year to date2. A letter from current employer on company letterhead stating:• Date employment began• 2013 earnings year to date or most recent check stub3. Statement or printout from Employment Security Office of 2013 Unemployment benefits received, ifapplicable.4. 2012 Federal IRS Tax Return Transcripts and all W-2s for you and your spouse or parent. To obtain anIRS Tax Return Transcript, go to www.irs.gov and click on the “order a Return or AccountTranscript” link, or call 1-800-908-9946. Make sure to request the “IRS tax return transcript” andnot the “IRS tax account transcript.”5. If military discharge, a copy of DD214.I lost my job with ___________________________________________________ on _______________.My year-to-date (YTD) earnings at this job were $__________.Please check one of the following and complete if necessary:I am currently receiving Unemployment benefits of $__________ weekly as of _______________.I am not currently receiving Unemployment benefits.If you have had a change in employment, complete the following:I am currently employed at __________________________________________ as of ________________.My weekly earnings at this job are $________________.B. Divorce or Separation Student Parent Divorce or Separation Date ________________Documents Required (Circle Status that Applies):1. Divorce: A copy of the divorce decree OR a signed statement from the attorney verifying the divorcedate OR a notarized statement verifying date of divorce.2. Separation: A copy of the legal separation document OR signed statement from the attorney verifyingthe date of separation OR a notarized statement verifying separation.3. 2012 Federal IRS Tax Return Transcripts and all W-2s for you and your spouse or parent. To obtain anIRS Tax Return Transcript, go to www.irs.gov and click on the “order a Return or AccountTranscript” link, or call 1-800-908-9946. Make sure to request the “IRS tax return transcript” andnot the “IRS tax account transcript.”

Student Name:_________________________________Student ID: ________________F. Other circumstances affecting financial status. Student Spouse ParentDocuments Required:1. Written statement explaining you and your spouse or parent circumstances that affects your financialstatus.2. Documentation to verify your statement.3. 2012 Federal IRS Tax Return Transcripts and all W-2s for you and your spouse or parent. To obtain anIRS Tax Return Transcript, go to www.irs.gov and click on the “order a Return or Account Transcript”link, or call 1-800-908-9946. Make sure to request the “IRS tax return transcript” and not the “IRS taxaccount transcript.”Each Special Circumstance Application is evaluated on an individual basis. You will be notified of thedecision through your college provided Gmail account.EXPLANATION of SPECIAL CIRCUMSTANCE_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FOR OFFICE OF FINANCIAL AID USE ONLYReviewed by: _________________________ Date: ______________ _____Approved _____DeniedReason: _____________________________________________________________________________Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________