Change in Student Circumstances Form 2011-2012 - Curry College

Financial Aid Appeal RequestAcademic Year 2011-2012Change in Student CircumstancesStudent’s Name______________________________________________ Curry ID # ________________PLEASE READ THE FOLLOWING CAREFULLY• If an appeal is filed, the reason must be thoroughly documented. Incomplete or undocumented appeals will notbe reviewed until all appropriate documentation has been received. Please note, once Curry College receives anappeal, we may request additional information to help us better understand your situation.• Students may file only one appeal in an academic year.• If not already selected by the Department of Education, all appeals will be selected for verification.• Once the Financial Aid Appeals Committee reviews your appeal, you will be notified of the outcome via writtencorrespondence within two weeks of receipt of the appeal.• The decision of the Financial Aid Appeals Committee is final.Reason(s) for AppealLoss of EmploymentCheck the situation that applies to your family and circle the appropriate person.□ Student / Spouse had work income in 2011 and has been unemployed for at least ten weeks in 2011.Date of Job Loss: ________________________________□ Student / Spouse had a significant reduction in work income in 2011due to an illness or disability.Date Reduction Occurred: _________________________□ Student / Spouse had a loss of untaxed income in 2011.Explain in detail ____________________________________________________________________□□CURRY COLLEGEStudent Financial Services1071 Blue Hill AvenueMilton, MA 02186-2395(617) 333-2354 Fax: (617) 333-2915Student was working full time but now cannot work due to returning to school full time.Other, explain in detail (attach a separate page if necessary)*:______________________________________________________________________________________________________________________________________________________*You must complete the Projected 2011 Income section of this form. Be sure to sign the CertificationStatement.***If your loss of job or income was for less than ten weeks of 2011, you may be asked to appeal inJanuary 2012 when actual 2011 income can be verified. If income decreases significantly, retroactivechanges to financial aid may be made.High Medical ExpensesComplete this section only if your family paid uninsured medical and dental expenses in excess of 4% ofstudent’s 2010 Adjusted Gross Income (AGI). If you itemized those expenses on their 2010 taxes, a copyof your Schedule A is sufficient documentation. If not, please attach receipts for all costs included in thetotal listed.Total uninsured medical/ dental expenses paid in 2010 $___________________________Other Special CircumstancesIf none of the above categories describe your family’s situation, attach an explanation of yourcircumstances with as much detail and documentation as possible. If your situation involves a change in income,complete The Projected Income Section on the reverse side.

Projected 2011 Income• Complete this section if you are appealing based on a loss of employment, or any other income-related change.• Attach any documentation you have for your figures, such as your most recent pay stubs, a letter from youremployer regarding severance package terms, etc.• Actual income will be verified in 2012. If changes were made to your financial aid based on yourprojections and the actual figures are higher than your projections, aid will be adjusted and you may berequired to repay financial aid received.• Enter “0” if no income of a certain type is expected.Estimated 2011 Taxable IncomeStudent’s 2011 work incomeSpouse’s 2011 work incomeSeverance compensationUnemployment compensationInterest and dividend incomeBusiness or real estate income/lossTaxable IRA/pension/annuity distributionOther taxable income(such as state tax refunds, alimony, capitalgain, taxable social security, etc.)Estimated 2011 Adjusted Gross Income (AGI)Estimated 2011 Net Federal Tax LiabilityEstimated 2011Income(01/01/11to 12/31/11)$_________________$_________________$_________________$_________________$_________________$_________________$_________________$_________________$_________________$_________________Estimated 2011 Untaxed IncomeUntaxed Social Security Benefits $__________ Earned Income Credit $__________Child support received for all children $__________ AFDC/ADC or TANF $__________Untaxed pension distributions $__________ Worker’s Compensation $__________Payments to IRA/401k/other plans $__________ Education tax credits $__________Tax exempt interest income $__________ Other untaxed income $__________(specify below)Cash/gifts paid on your behalf $__________ _________________________________Certification StatementThe information provided on this form is accurate and complete to the best of our knowledge. I/We haveprovided our signed 2010 federal tax returns, including all schedules and W-2 statements along with acompleted Verification Worksheet. I/We understand that completing this form does not guarantee financialaid will be increased. I/We also understand that if financial aid is revised based on this appeal information,2011 income as reported will be verified in 2012 and financial aid may be revised and may have to be repaidif our estimates were inaccurate. I/We agree to notify Student Financial Services if our income changes.Student’s Signature_________________________________________________Date_______________________Spouse’s Signature ________________________________________________ Date_______________________