STEPHENS COLLEGE Financial Aid Office
2018-2019 Special Circumstance Application
Student’s Name: ______
Last First MI
Student’s Social Security Number (last 4 digits): X X X - X X - ______
Address: ______
Street City State Zip
Home Phone: ( ) ______- ______
You may use this 2018-2019 Special Circumstance Application to request a review of extenuating circumstances not represented on the original Free Application for Federal Student Aid (FAFSA). Use this form only if you meet one of the criteria listed in Part I below.
PLEASE NOTE: This application cannot be reviewed until we receive all documents requested and income verification has been completed. Attach all documents pertinent to your specific situation to this form. Return this form and the required documentation to the Financial Aid Office. If a professional judgement is made, results will be indicated on a revised award notification.
This form with required documentation must be submitted prior to the end of the academic period that the student is currently enrolled in.
After submitting this Special Circumstance Application and the required documentation to the Financial Aid Office, your request will be considered. Requests submitted without the required supporting documentation will not be reviewed.
Part I: The 2018-2019 Income Reduction Is Due To (check one or more of the following):
A. Death of a parent and/or spouse
B. Unusually high medical and/or dental expenses
C. Divorce/Separation
D. Tuition expenses at an elementary or secondary school for 2017-2018 academic year
Part II: You must provide the following information and/or supporting documents for each category selected in Part I.
- Death of a parent or spouse
Parent(s)/spouse whose 2016 income was reported on the Free Application for Federal Student Aid is now deceased:
Provide copies of deceased parent or spouse 2016 W2 forms.
Provide a copy of death certificate.
- Unusually high medical and/or dental expenses not covered by insurance
Please list total medical/dental expenses not covered by insurance during 2017. This amount should reflect actual expenses paid during 2017 and should NOT include unpaid debts incurred or expenses that are paid by insurance.
You must attach copies of paid receipts, cancelled checks, or other supporting documents, which verify total amount paid. Please highlight the amount(s) paid on supporting documents.
Total Amount Paid: $ ______
- Divorce/Separation
As a student with dependent status, your parents have separated or divorced after you filed your 2018-2019 Free Application for Federal Student Aid (FAFSA).
Date of separation or divorce: ______
Provide a copy of divorce decree.
Provide copies of student and parent(s)’ 2016 Federal Tax Transcript, 2016 W2s, and complete the Verification Worksheet.
- Tuition expenses at an elementary or secondary school
Your family has tuition expenses at an elementary or secondary school. Do NOT include any tuition paid towards post-secondary education or tuition paid during 2017 for applicant.
Complete section below and list total tuition paid during 2017.
Provide documentation verifying student enrollment and 2017 paid tuition.
Student’s Name Institution Cost
______$______
______$______
Total $______
I/we declare under penalty of perjury that the information provided for this request is true and correct. If approved, I understand and agree the Financial Aid Office will make necessary changes electronically on my and/or my parent’s behalf.
Student’s Signature: ______Date:______
Parent’s Signature: ______Date:______