Student Name: _____________________________________________________________________________________
Student ID: _________________________________ OR Social Security Number: X X X – X X – ___ ___ ___ ___
Use this form to report the death of a parent of a dependent student or the spouse of an independent student.
1. Name of deceased parent/spouse: __________________________________________________
2. Date of death (mmddccyy): _______________________________
3. Complete the chart below. Indicate the actual and/or anticipated monthly gross income of the remaining parent (for
a dependent student) or yourself (for an independent student). Also include the actual and/or anticipated funds
received from death benefits (e.g., life insurance, social security benefits, etc.). Please contact the Financial Aid Office
for further instructions in the case of a dependent student who loses both parents.
EACH FIELD MUST CONTAIN A NUMERIC VALUE. ENTER $0, IF APPLICABLE.
July August September October November December
2017 2017 2017 2017 2017 2017
January February March April May June
2018 2018 2018 2018 2018 2018
4. Attach required documentation:
a. Death Certificate
b. 2015 Federal Income Tax Return
c. Student’s or remaining parent’s 2015 W2 form(s)
d. Life Insurance Policy (if applicable)
e. Social Security Statement (if applicable)
f. Documentation supporting each benefit and a separate page explaining what was done with the funds (e.g.,
itemization of funeral expenses)
Validation Statement: I certify the information provided is complete and true to the best of my knowledge. Furthermore,
I agree to contact the Financial Aid Office at the time there are changes to the situation on which the request for exception
has been founded. I understand that changes made to my student financial aid eligibility based upon the information
provided may affect only the student financial aid received at Indiana Wesleyan University for the 2017-2018 award year.
_________________________________________________________________________ ______________________
Student Signature Date
_
________________________________________________________________________ ______________________
Parent Signature (for dependent student only) Date
Mail, email, or fax completed form and supporting documentation to:
Financial Aid Office, IWU-National & Global 1900 West 50
th
Street Marion, IN 46953-9393 indwes.edu
800.621.8667 option 4 765.677.2516 765.677.2030 Fax IWUfinaid@indwes.edu
NOTE: If you are receiving a set amount of income or benefits
on a weekly basis for the entire duration of July 2017 through
June 2018, please keep in mind that there are on average more
than 4 weeks per month. To correctly calculate monthly
amounts, you must multiply the weekly amount by 4.3333
DEATH OF A PARENT OR SPOUSE
