Special Circumstance Appeal Form - Indiana University Southeast

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Special Circumstance Appeal Form - Indiana University Southeast

INDIANA UNIVERSITY SOUTHEASTDEPENDENT STUDENTSpecial Circumstances Appeal FormAcademic Year/SummerOffice of Financial AidIndiana University Southeast4201 Grant Line RoadUniversity South 105New Albany, IN 47150(812) 941-2246 Fax (812) 941-2546Web site: http://www.ius.edu/financialaidOneStart: http://onestart.iu.eduAppeal and all required documentation submitted no later than 30 days before the last day of the semester.Process: Appeals are reviewed by committee and are subject to federal guidelines. If approved, changes are submitted to the U.S.Department of Education (FAFSA) and financial aid will be adjusted once approved. We cannot make adjustments withoutdocumentation and if the student makes these adjustments to the FAFSA on their own those changes will be rejected or triggeradditional verification, which could result in the loss of existing eligibility for aid.Appeals may be closed without a ruling if the requested changes would not improve the student’s financial aid.STEP 1: Contact Information and AcknowledgementStudent Name (print): __________________________________________ IU Student ID: _000-_____________________Phone________________________E-Mail(username):____________________@ius.eduParent Name(s) (print): _____________________________________________________ Phone________________________READ and SIGN:I give permission to the Financial Aid office to verify any information I provide. I understand that this verification may include a requestfor copies of my tax and/or financial documents. I certify that all of the information provided for this appeal is correct to the best ofmy knowledge. I understand that if I purposely give false or misleading information, I am liable for cancellation or repayment of all orpart of my financial aid.I acknowledge that all communication regarding this appeal will be sent to my (the student) IU email account.Student Signature: ____________________________________________ Date: _______________________________Parent Signature: ____________________________________________ Date: _______________________________STEP 2: VerificationBefore adjustments can be made for special circumstances the information you submitted on the FAFSA must be checked for accuracy.Verification forms are included with the special circumstance form for your convenience and listed below. In addition to otherdocumentation noted on page 2, the student and/or parent must provide SIGNED COPIES of the following. Only the parent(s)whose information is on the student’s FAFSA should provide the requested parent documents:DEPENDENT household formStudent federal tax return (with signature added) and W-2’s ORParent(s) federal tax return (with signature added) and W-2’s ORStudent NON-TAX FILER form if the student did not file.Parent NON-TAX FILER form if the parent(s) did not file.CHILD SUPPORT FORM – IF someone listed on the Household Form PAID child support in the previous tax year.SNAP FORM – IF someone listed on the Household Form received SNAP benefits within the last two years OR has recentlyapplied for or begun receiving SNAP benefits this year.


STEP 3: Special Circumstance Documentation: Select all that applyStudent name: _________________________________ Page 2INCOME:Student and/or parent expects a significant decrease in income from the previous year.Person(s) who lost income: student father/step-father mother/step-motherJob loss/change was: voluntary involuntary _______________________________________________Additional Documentation (include all that apply):Job loss: Unemployment Benefit Statement, severance package and/or letter from employer confirming job lossJob change: Most recent pay stub of new job and proof of start date, last pay stub of previous job and proof of end dateRetirement/Disability: Disabilities Benefit Statement, Retirement or Social Security Benefit StatementReturning to school – quit or reduced hours: most recent paystub, letter showing date of resignation/job loss or reduction in hoursMEDICAL EXPENSES: Family paid extraordinary non-reimbursed medical costs during previous year.Documentation: Proof of all non-reimbursed medical and/or dental expenses paid during the previous year for anyone listed onthe Household Information form, including insurance premiums. Only include expenses actually paid by the student or parents.If you filed a federal 1040 tax return and you itemized your tax deductions, the amount listed on your 1040 Schedule A form can beused and a copy of this form will be sufficient evidence. If you did not itemize, provide an estimate of your expenses. A simulationwill be run to determine if your expenses are high enough to make a difference in your aid and if so will notify you of thedocumentation we will require.Estimated unreimbursed medical expenses paid in previous year: ____________________NATURAL DISASTER: Family has incurred extraordinary non-reimbursed living expenses in or after January ofthe previous year due to a disaster. Examples include tornado, flood, fire, storm damage. Please provide an itemized statementshowing expenses incurred and payments made as well as documentation of the circumstance.Documentation:Insurance claim/denialReceipts for damage and repair costs as well as extra living expenses paid for in or after previous yearBriefly describe the involuntary and/or extraordinary circumstances that led to your situation:MARITAL STATUS: Parent has become separated, divorced, widowed or married since filing the FAFSA.Parent became separated divorced widowed married on: (date)_________________ __________Copy of the marriage certificate or proof of other changes in marital status (divorce or separation papers, obituary)A copy of spouse’s previous year W-2’s, and also a copy of their tax return if you did not file jointlyIf the student’s last name has been changed through the Social Security Administration a copy of the new SS CardNumber in Household: Number of members in the household has increased since filing the FAFSA. Refer to theDependent Household Information form to know who to include in the household.Documentation: Show all members on the Dependent Household Form requested in Step 2.Number in College: Number of members in the household attending college has increased since filing the FAFSA.Must be attending at least ½ time and working toward a college degree or certificate. Parents can only be included if they are notreceiving any financial assistance for their own degree.Documentation: Indicate college(s) on the Dependent Household Form requested in Step 2 ANDCopy of unofficial transcript showing enrollment and degree objective if not an IU student.


2012 NON TAX FILER FORMDEPENDENT STUDENT2013/2014 AID YEARPlease complete, print, sign, and submit to campus address listed at the bottom of this formStudent Name(Please Print)Last First MiddleStudent ID NumberBased on the information provided on your Free Application for Federal Student Aid (FAFSA) you indicated you willnot and are not required to file a 2012 income tax return with the IRS.Check the box that applies:I was not employed and had no income earned from work in 2012I was employed in 2012 and listed below the name of all my employers, the amount earned from each employerin 2012 and whether an IRS W-2 form is attached.** Attach copies of all 2012 IRS W-2 forms. List every employer even if they did not issue an IRS W-2 form.Employer’s Name 2012 Amount Earned IRS W-2 Issued byemployerIRS W-2 AttachedSusie’s Auto Body Shop (example) $2,000 (example) Yes (example) Yes (example)Certification and Signature: Signing this form certifies all of the information reported is complete and correct.Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail,or both.Student SignatureForm must be signed after printing, an electronic signature will not be accepted.DateParent SignatureForm must be signed after printing, an electronic signature will not be accepted.DateOffice of Financial Aid ▪ 4201 Grant Line Rd ▪ University Center South 105 ▪ New Albany, IN 47150Phone: (812) 941-2246 ▪ Fax: (812) 941-2546 ▪ Email: financialaid@ius.edu


2012 NON TAX FILER FORMPARENT2013/2014 AID YEARPlease complete, print, sign, and submit to campus address listed at the bottom of this formStudent Name(Please Print)Last First MiddleStudent ID NumberBased on the information provided on your Free Application for Federal Student Aid (FAFSA) your parent(s) indicatedthey will not and are not required to file a 2012 income tax return with the IRS.Check the box that applies:My parent(s) were not employed and had no income earned from work in 2012My parent(s) were employed in 2012 and listed below are the names of all their employers, the amountearned from each employer in 2012 and whether an IRS W-2 form is attached.** Attach copies of all 2012 IRS W-2 forms. List every employer even if they did not issue an IRS W-2 form.Employer’s Name 2012 Amount Earned IRS W-2 Issued byemployerIRS W-2 AttachedSusie’s Auto Body Shop (example) $2,000 (example) Yes (example) Yes (example)Certification and Signature: Signing this form certifies all of the information reported is complete and correct.Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail,or both.Student SignatureForm must be signed after printing, an electronic signature will not be accepted.DateParent SignatureForm must be signed after printing, an electronic signature will not be accepted.DateOffice of Financial Aid ▪ 4201 Grant Line Rd ▪ University Center South 105 ▪ New Albany, IN 47150Phone: (812) 941-2246 ▪ Fax: (812) 941-2546 ▪ Email: financialaid@ius.edu


HOUSEHOLD INFORMATION FORMDEPENDENT STUDENT2013/2014 AID YEARPlease complete, print, sign, and submit to campus address listed at the bottom of this formStudent Name(Please Print)Last First MiddleStudent ID NumberDependent Student Family Information: List below the people in your parent(s)’ household. Include:Yourself and your parent(s), including a step-parent, even if you do not live with your parent(s). Your parent(s) other children if your parent(s) will provide more than half of their support from July 1, 2013 through June 30,2014, or if the other children would be required to provide parental information if they were completing a FAFSA for 2013-2014.Include children who meet these standards, even if they do not live with your parent(s).Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will continue toprovide more than half of their support through June 30, 2014 Please Note: This does not include foster children who mayreside in the household.Include the name of the college for any household member, excluding your parent(s), who will be enrolled, at least half-time in adegree, diploma, or certificate program any time between July 1, 2013, and June 30, 2014.Full Name of Household Member Age Relationship to Student Name of CollegeStudentIndiana UniversityParent / Step-ParentN/ACertification and Signatures: Each person signing this form certifies all of the information reported is completeand correct. The student and one parent must sign and date the form. Warning: If you purposely give false ormisleading information on this form you may be fined, be sentenced to jail, or both.Student SignatureParent SignatureForm must be signed after printing, an electronic signature will not be accepted.Form must be signed after printing, an electronic signature will not be accepted.DateDateOffice of Financial Aid ▪ 4201 Grant Line Rd ▪ University Center South 105 ▪ New Albany, IN 47150Phone: (812) 941-2246 ▪ Fax: (812) 941-2546 ▪ Email: financialaid@ius.edu


SUPPLEMENTAL NUTRITION ASSISTANCEPROGRAM FORMDEPENDENT STUDENT2013/2014 AID YEARPlease complete, print, sign, and submit to campus address listed at the bottom of this formStudent Name(Please Print)Last First MiddleStudent ID NumberBased on the information provided on your Free Application for Federal Student Aid (FAFSA) you and at least oneparent whose information was included on your FAFSA must complete, sign and submit this form. Check the boxbelow that applies to your parent(s) household.YES - One of the persons included in my parent(s) household received benefits from the Supplemental NutritionAssistance Program (SNAP) in 2011 or 2012.NO - No one included in my parent(s) household received benefits from the Supplemental Nutrition AssistanceProgram (SNAP) in 2011 or 2012.According to the FAFSA instructions, the people in your parent(s) household include:Yourself and your parent(s), including step-parent, even if you do not live with your parent(s). Your parent(s) other children if your parent(s) will provide more than half of their support from July 1, 2013 through June 30,2014, or if the other children would be required to provide parental information if they were completing a FAFSA for 2013-2014.Include children who meet these standards, even if they do not live with your parent(s).Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will continue toprovide more than half of their support through June 30, 2014. Please Note: This does not include foster children that mayreside in the household.Certification and Signatures: Each person signing this form certifies all of the information reported is completeand correct. If asked, I will provide documentation of the receipt of benefits during 2011 and/or 2012. The studentand one parent must sign and date the form. Warning: If you purposely give false or misleading information on thisform you may be fined, be sentenced to jail, or both.Student SignatureForm must be signed after printing, an electronic signature will not be accepted.DateParent SignatureForm must be signed after printing, an electronic signature will not be accepted.DateOffice of Financial Aid ▪ 4201 Grant Line Rd ▪ University Center South 105 ▪ New Albany, IN 47150Phone: (812) 941-2246 ▪ Fax: (812) 941-2546 ▪ Email: financialaid@ius.edu


CHILD SUPPORT PAID FORMDEPENDENT STUDENT2013/2014 AID YEARPlease complete, print, sign, and submit to campus address listed at the bottom of this formStudent Name(Please Print)Last First MiddleStudent ID NumberBased on the information provided on your Free Application for Federal Student Aid (FAFSA) one or both of yourparent(s) reported they paid child support in 2012 for a child not included in your household. Please indicate below,the name of the person who paid the child support, the name of the person to whom the child support was paid, thenames of the children for whom child support was paid, and the total annual amount of child support that was paid in2012 for each child.Name of Person Who PaidChild SupportName of Person to WhomChild Support was PaidName of Child for WhomSupport was PaidAnnual Amount ofChild Support Paidin 2012Marty Jones (example) Chris Smith (example) Terry Jones (example) $6,000 (example)The amount of Child Support Paid reported on the FAFSA was listed in error. One or both of my parent(s)did not pay child support in 2012 for a child not included in their household.Certification and Signatures: Each person signing this form certifies all of the information reported is completeand correct. If asked, I will provide documentation of the payment of child support. The student and one parentmust sign and date the form. Warning: If you purposely give false or misleading information on this form you maybe fined, be sentenced to jail, or both.Student SignatureForm must be signed after printing, an electronic signature will not be accepted.DateParent SignatureForm must be signed after printing, an electronic signature will not be accepted.DateOffice of Financial Aid ▪ 4201 Grant Line Rd ▪ University Center South 105 ▪ New Albany, IN 47150Phone: (812) 941-2246 ▪ Fax: (812) 941-2546 ▪ Email: financialaid@ius.edu

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