University of Minnesota Crookston
DEPENDANT SPECIAL CIRCUMSTANCE APPEAL
Academic Year 2016-2017Office of Financial Aid & Scholarships University of Minnesota Crookston 170 Owen Hall, 2900 University Ave. Crookston, MN 56716
Phone: 218/281-8569 Fax: 218/281-8575
According to federal laws and regulations, a family’s 2015 income is used to assess financial need for the 2016- 2017 school year. If a family’s income is lower due to special circumstances, a financial aid administrator may be able to use the 2016 income or projected income to assess financial need. Please provide information
regarding your reduction in income by completing this form.
Student Information
Student’s Name (last, first, middle
initial) Birthdate Social Security Number Student ID number
Address (street or P.O. box number, city, state, ZIP) Phone Number
This application should be used by dependent students and their parents whose financial situation has changed and 2015 tax information does not accurately reflect the family’s current financial condition. This change may be due to loss of job, separation or divorce, disability, death, unusual expenses, or other circumstances.
As you may be aware, financial aid eligibility for 2016-2017 is calculated based on the student’s and parent’s 2015 federal income tax returns. Therefore, before a request for special consideration will be reviewed by UMC, the student must make an application for federal financial aid using the FAFSA and using 2015 tax information. After completing and mailing the FAFSA, you may then complete this application if you and your family wish to apply for the review of your special circumstances. Return this application to the Office of Financial Aid and Scholarships, 170 Owen Hall, 2900 University Ave, Crookston, MN 56716.
NEEDED DOCUMENTATION
Depending on the circumstance, various documentation may be needed to support your situation. For the financial aid office to approve a request for special consideration, documentation must be thorough and complete. It is the student and parent’s responsibility to provide all needed documentation to support their special circumstance. Provide any documentation you feel would help support your situation.
Please check which situation applies to your circumstance and provide the necessary documentation:
For ALL circumstances – A detailed statement describing the situation. On an additional piece of paper,
describe in detail the situation which is causing you to apply for special consideration. Be concise, and include the date when the situation you are describing occurred.
Date when situation described occurred: Month _ Day Year
For loss of job – A letter from the former employer or other documentation of loss of job and a letter from a
pastor, counselor, accountant, attorney or other professional attesting to the parent’s loss of job. This situation must be in effect for at least three months before a change in circumstances will be considered.
For unusual medical expenses – A detailed explanation of the situation, copies of all expense receipts and
insurance papers, and an itemized listing showing type of expense and the total amount you have paid. Our office assumes you have health insurance so only costs not covered by insurance or another agency may be considered. These expenses must be at least $2,200.
For loss of unemployment benefits – A statement from the Employment commission showing amount of
benefits received, dates received, and date terminated.
For divorce or separation – Copy of divorce documents or notarized statement from both parents attesting
to; the separation, date of separation or divorce, and a separation of income statement (including 2015 Federal Tax return and W-2’s).
For disability - Statement from physician as to nature and condition of disability and date disability began. For death – A copy of official death certificate.
Other -Please submit documentation that you believe is appropriate for your situation.
It is impossible to list all situations and the documentation needed. The financial aid office reserves the right to request additional documentation at its discretion. You will be notified if other items are needed.
Section 1. Student Information
Name Student ID Date
Address Phone
City State Zip
List all family members included on your 2016-2017 FAFSA (If you need additional space, you may add more family
members in your personal statement).
Name Birth Date Relationship to Student College attended from July 1, 2016 to June 30, 2017 Social Security Number Self University of Minnesota Crookston
Father Mother Sibling
Section 2. Income Source Table
January 1 through December 31, 2016 1/1/16 - today Actual Estimated
Today - 12/31/16 Actual+Estimated Total Income earned from work by father (wages, salary, & tips)
Income earned from work by mother (wages, salary, & tips) Income earned from work by student (wages, salary, & tips) Business, farm, or rental income
Interest/dividend income, specify below by source & value:
$ $
Unemployment compensation Capital gains
Spousal maintenance Child support
Welfare benefits (such as AFDC or TANF) Veterans benefits
Social Security benefits (including SSI) Workers’ compensation
Short-term or long-term disability benefits Severance pay
Withdrawal from retirement account
SECTION 3: FAFSA Additional Information Tables, Calendar Year 2015
Items to review. We need these items to be reviewed if your family reported dollar amounts on lines 91 and 92 of your 2016
FAFSA. Enter a $0 next to any item that does not apply to your parents. Please report annual amounts.
Q91. Parents’ 2015 Additional Financial Information (Enter the amounts for your
parent[s]). 2015 FAFSA 2016 Estimate
a. Education credits (Hope & Lifetime Learning tax credits) from IRS Form 1040-line
49 or 1040A-line 31. $ $
b. Child support paid because of divorce or separation or as a result of a legal requirement. Don’t include support for children in your parents’ household, as
reported in question 72. $ $
c. Your parents’ taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and
assistantships. $ $
d. Your parents’ taxable student grant and scholarship aid reported to the IRS in your parents’ adjusted gross income. Includes AmeriCorps benefits (awards, living allowances and interest accrual payments), as well as grant and scholarship portions of fellowships & assistantships.
$ $
e. Combat pay or special combat pay. Only enter the amount that was taxable and included in your parents’ adjusted gross income. Do not enter untaxed combat pay
reported on the W-2 (Box 12, Code Q). $ $ f. Earnings from work under a cooperative education program offered by a college. $
Q92. Parents’ 2015 Untaxed Income (Enter the amounts for your parent[s]). 2015 FAFSA
$
2016 Estimate
a. Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including, but not limited to, amounts reported on the W-2 forms in Boxes
12a through 12d, codes D, E, F, G, H, and S. $ $ b. IRA deductions and payments to self-employed SEP, SIMPLE, Keough, and other
qualified plans from IRS Form 1040-line 28 + line 32 or 1040A-line 17. $ $ c. Child support received for any of your children. Don’t include foster or adoption
payments. $ $
d. Tax exempt interest from IRS Form 1040-line 8b or 1040A-line 8b. $ $ e. Untaxed portions of IRA distributions from IRS Form 1040-lines (15a – 15b) or
1040A-lines (11a – 11b). Exclude rollovers. If negative, enter a 0 here. $ $ f. Untaxed portions of pensions from IRS Form 1040-lines (16a – 16b) or 1040A-lines
(12a – 12b). Exclude rollovers. If negative, enter a 0 here. $ $ g. Housing, food, and other living allowances paid to members of the military, clergy,
and others (including cash payments and cash value of benefits). Don’t include the value of on-base military housing or the value of a basic military allowance for housing.
$ $
h. Veterans noneducation benefits such as Disability, Death Pension, or Dependency &
Indemnity Compensation (DIC) and/or VA Educational Work-Study Allowances. $ $ i. Other untaxed income not reported in items 92a through 92h, such as workers’
compensation, disability, etc.
Don’t include student aid, earned income credit, additional child tax credit, welfare
payments, untaxed Social Security benefits, Supplemental Security Income, Workforce Investment Act educational benefits, on-base military housing or a military housing allowance, combat pay, benefits from flexible spending
arrangements (e.g., cafeteria plans), foreign income exclusion or credit for federal tax on special fuels.
We certify, by signing below, that all of the information reported on this application is true and complete to the best of our knowledge. If asked by a financial aid administrator, we agree to provide proof of the
information we have reported, including but not limited to copies of 2015 federal tax returns, W-2 forms and schedules. We also understand that failure to provide any documentation requested will result in denial of this application.
Certification
You must sign this form certifying that the information you provided is true. Misrepresentation of facts in connection with this form may be sufficient cause, in and of itself, for cancellation or repayment of financial aid, whenever discovered.
Student Signature Date Signed
Father’s Signature Date Signed
Mother’s Signature Date Signed
OFFICE USE ONLY
Action taken FAA signature Date
New AGI: New tax paid
New Father income New mother income
Untaxed income New student income
Old EFC: New EFC:
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