Student Name: _____________________________________________________________________________________
Student ID: _________________________________ OR Social Security Number: X X X – X X – ___ ___ ___ ___
Use this form to report payment of excessive medical expenses. Consideration is given to a family’s payment of excessive
medical expenses not covered by their insurance. Information for determining what costs are acceptable and what costs
are excluded can be found in the IRS Tax Form 1040, Schedule A instructions. We cannot consider amounts billed but not
paid.
1. Complete the chart below with the out-of-pocket amount paid per month toward medical expenses. Scheduled
monthly payments will be considered with attached documentation showing the monthly contract or payment
arrangement made.
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
2. Attach required documentation:
a. Documentation or a statement explaining the medical condition(s)
b. 2015 Federal Income Tax Return
c. 2015 Schedule A (if an itemized return)
d. Billing contract(s)/payment schedule(s)(if applicable)
e. Paid receipts
f. Insurance claim(s) showing amounts paid and/or denied
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
for the entire duration of July
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 (weeks).
EXCESSIVE MEDICAL EXPENSES
FINANCIAL AID OFFICE
