Fillable 14 15 Dependent Income Change Appeal (Eastern Wyoming College)

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14 15 Dependent Income Change Appeal (Eastern Wyoming College)

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U.S.A. forms for Eastern Wyoming College

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REQUIRED DOCUMENTATION
Mail: Financial Aid Office
Eastern Wyoming College
3200 West C Street
Torrington, WY 82240
Fax: 307-532-8222
2014-2015
Income Change/Special
Circumstance Appeal
(Dependent student)
PLEASE NOTE: You must have filed a 2014-2015 Free Application for Federal Student Aid (FAFSA) and have
received your results BEFORE submitting this form. All appeals must contain supporting documentation.
Unsigned, incomplete or inadequately documented forms will not be considered. Submission of an appeal
does not imply your request will be approved. Appeals should be submitted as soon as possible, but no later
than mid-term of the semester for which the student is requesting aid.
Financial need is partially based on the student’s and his/her parent(s)’ gross annual income for the previous tax year.
If your family’s income has recently decreased or you have special financial issues that were not taken into account
on your FAFSA, we may be able to re-evaluate your financial need based on your family’s projected gross income
for the 2014 tax year (January 1, 2014 to December 31, 2014). For dependent students, we consider changes in
income for the student’s parent(s) only.
You will be notified in writing of the Appeal Committee’s decision. Allow 30 days for review. Additional time may
be needed for review if the Financial Aid Office requests additional information. If we are able to make adjustments,
we will submit corrections to your FAFSA data. If you qualify for additional aid based on your adjusted financial need,
we will award the additional aid when the correction process is complete. This correction process could take up to two
more weeks, depending on the time of year.
WHAT IS A “SPECIAL CIRCUMSTANCE”?
Special circumstances are usually defined as unexpected events or situations beyond your control.
Examples include
(but are not limited to): loss of employment, reduction in hours, loss of benefits such as Social Security or child
support, disability, separation or divorce after filing the FAFSA, death of a parent after filing the FAFSA.
WHAT IS NOT ELIGIBLE FOR APPEAL? (not limited to these examples)
• Routine personal living expenses (car payments, insurance, credit card bills, mortgage/rent)
• Unusual personal living expenses (wedding costs, legal expenses)
• Reduction in overtime pay
• Bankruptcy
• One-time income from gambling earnings
INSTRUCTIONS
 Complete this form only if your family’s gross income has decreased at least 20% from what it was the
previous year.
In addition to completing this form and providing all situation-specific supporting documentation, all appeals must include the
following documentation:
A typed (or neatly hand-written), signed statement explaining your family’s special circumstances
Signed copy of your 2013 Federal Income Tax Return (or Tax Transcript) and W-2 forms
Signed copy of your parent(s)’ 2013 Federal Income Tax Return (or Tax Transcript) and W-2 forms
A copy of the most recent pay stub from each employer
Verification of all untaxed income received in 2013
Complete the Estimated Income/Expenses Worksheet on page 4
Appeals submitted after 12/31/14 MUST include signed copies of 2014 Federal Income Tax Returns and W-2 forms
*Please note that omitting required documentation may cause delays in your appeal’s review or your appeal may be denied.
A: STUDENT INFORMATION
B: REASON FOR SUBMITTING APPEAL (check all that apply)
______________________________________________________________ ________________________________________
Last Name First Name M.I. EWC Student ID Number
______________________________________________________________ ________________________________________
Address (include apartment number) Social Security Number (Last 4 digits)
______________________________________________________________ ________________________________________
City, ST, Zip Phone Number (Include area code)
A. Unemployment or reduction of hours or wages
Parent who worked in 2013 is now unemployed or has had work hours and/or wage rate reduced.
Required documentation:
o Copy of last pay stub(s) from previous employer(s)
o Copy of letter from employer on letterhead verifying the release from employment or reduction in hours/wages, the
date the change became effective and the duration of the reduction if temporary
o Notice of eligibility or denial for unemployment benefits
o Copy of disability benefit statement if applicable
B. Medical or dental expenses
You or your parent(s) made payments for expenses not covered by insurance. Medical expenses for which you received
no insurance or other reimbursement must exceed 11% of the family’s taxable income in order to be considered for
appeal.
Required documentation:
o Submit copies of receipts or billing statements showing amounts
for which you received no insurance or other
reimbursement, as well as documentation of payment.
o Total medical expenses for which you received no insurance or other reimbursement(s): $__________________.
C. Retirement
Parent who worked in 2013 has retired.
Required documentation:
o Copy of last pay stub(s) from previous employer(s)
o Copy of retirement benefit statement
o Letter from previous employer on letterhead stating last date of employment
D. Death of parent
Parent passed away after the FAFSA was filed.
Required documentation:
o Copy of death certificate, obituary, or funeral program
E. Separation or divorce of parent
Parent was married when the FAFSA was filed, but has now separated or divorced.
Required documentation:
o Court documentation verifying legal separation or divorce, or letter from attorney documenting that legal proceedings
have begun
F. Reduction or loss of support or benefits
Student or parent received support or benefits in 2013 that have been terminated or reduced. Support or benefits may
include: worker’s compensation, unemployment benefits, child support, Social Security benefits, pensions, etc.
Required documentation:
o Last check stub or printout of benefit received
o Letter from agency on letterhead verifying the date and amount of benefit lost
C: EXPLANATION OF SPECIAL CIRCUMSTANCES
G. One-time income
Student or parent received non-recurring income in 2013 from a pension, IRA, annuity, inheritance, settlement, etc.
Required documentation:
o Copy of form 1099 or other statement from paying agency showing the one-time income
o Explain why the one-time income is not available for education expenses; include documentation
H. Dislocated Worker/Displaced Homemaker
Parent is a Dislocated Worker if he/she is receiving unemployment benefits due to being laid off or losing a job and is
unlikely to return to a previous occupation or was self-employed but is now unemployed due to economic conditions or
natural disaster. A Displaced Homemaker is generally a person who previously provided unpaid services to the family
(e.g. stay-at-home parent), is no longer supported by the spouse, is unemployed or underemployed, and is having trouble
finding or upgrading employment.
Required documentation:
o Copy of letter from employer on letterhead verifying the release from employment or reduction in hours/wages, the
date the change became effective and the duration of the reduction if temporary
o Notice of eligibility or denial for unemployment benefits
I. Other
You or your parent(s) have other unusual circumstances not listed above.
Required documentation:
o Explain the circumstances in detail, including the impact on your ability to pay for your educational expenses
o Attach supporting documentation of the circumstances
Whose income decreased (check all that apply)?
□ Student □ Student’s mother □ Student’s father
What date did the change in circumstance occur? ______/______/______
*Explain below (or attach a typed, signed personal statement explaining), in as much detail as possible
, why you are requesting
a change in income. Please list dates that the changes occurred and how it impacted your income. You must provide
appropriate documentation. Be as detailed as possible about the change in your circumstances.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________
E: CERTIFICATION AND SIGNATURE
The following section requires you to provide your and your parent(s)’ expected income for 2014. Please provide figures for the
entire year; do not report hourly or monthly wages or income. Include all income received from January 1, 2014 until now, and estimate
amounts to be received from now until December 31, 2014. This form may be completed in pencil.
Do not leave any line blank. List the yearly amount you expect to pay in expenses and receive from income in 2014. If no
income/expenses are expected, you MUST write “$0”.
EXPENSES FOR 2014
JAN. 2014—TODAY TODAY—DEC. 2014 TOTAL
Rent/mortgage $__________________ $__________________ $_______________
Utilities $__________________ $__________________ $_______________
Insurance: Home/apartment $__________________ $__________________ $_______________
Auto $__________________ $__________________ $_______________ No line
Tuition/fees (paid for dependents) $__________________ $__________________ $_______________ may be
Food $__________________ $__________________ $_______________ left blank!
Clothing $__________________ $__________________ $_______________ If $0, please
Transportation (gas, repairs) $__________________ $__________________ $_______________ provide an
Car payments/lease $__________________ $__________________ $_______________ explanation
Unreimbursed medical/dental $__________________ $__________________ $_______________ on a separate
Recreation $__________________ $__________________ $_______________ form.
Other (specify): ____________ $__________________ $__________________ $_______________
____________ $__________________ $__________________ $_______________
TOTAL EXPENSES: $__________________ $__________________ $_______________
INCOME FOR 2014 JAN. 2014—TODAY TODAY—DEC. 2014 TOTAL
Student’s gross income from work $__________________ $__________________ $_______________
Mother’s gross income from work $__________________ $__________________ $_______________ If your total
Father’s gross income from work $__________________ $__________________ $_______________ expenses
Interest/dividend income $__________________ $__________________ $_______________ exceed your
Pensions/annuities $__________________ $__________________ $_______________ total income,
Unemployment compensation $__________________ $__________________ $_______________ you must
Severance pay $__________________ $__________________ $_______________ provide a
Social Security benefits $__________________ $__________________ $_______________ detailed
Veterans benefits $__________________ $__________________ $_______________ explanation
Child support received $__________________ $__________________ $_______________ of how you
AFDC/TANF/SNAP $__________________ $__________________ $_______________ plan to meet
Financial aid $__________________ $__________________ $_______________ expenses.
Other (specify): ____________ $__________________ $__________________ $_______________
TOTAL INCOME: $__________________ $__________________ $_______________
By signing this worksheet, I/we certify that all of the information reported is complete and correct. I/we also acknowledge that I/we
have read and agree to comply with all verification policies as stated by EWC. Failure to submit information in a timely fashion
may result in the application being filed as inactive with no further consideration and no federal aid for the academic year.
Student signature: ___________________________________________________ Date:___________________________
Parent signature: ____________________________________________________ Date:___________________________
Printed names: ________________________________________________________________________________________
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
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14 15 Dependent Income Change Appeal (Eastern Wyoming College)

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Completed 25 July 2020

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