Student Name: _____________________________________________________________________________________
Student ID: _________________________________ OR Social Security Number: X X X – X X – ___ ___ ___ ___
Use this form to report the loss of child support benefits received for the parent of a dependent student or, for
independent students, the student or student’s spouse.
1. Name of the family member who experienced the loss of child support benefits: _____________________________
2. Relationship to the student of the family member who experienced the loss of child support benefits:
(check one)
3. Date of loss of child support benefits: _______________________
4. Reason for the loss of benefits: ______________________________________________________________________
5. Complete the chart below with actual and/or anticipated monthly amounts of child support benefits received.
July August September October November December
2017 2017 2017 2017 2017 2017
January February March April May June
2018 2018 2018 2018 2018 2018
6. Attach required documentation:
a. Court document supporting the termination of child support benefits
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
LOSS OF CHILD SUPPORT
NOTE: If you are receiving a set amount of child support 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 (weeks).
Student's (Step) Mother _____ Student's (Step) Father _____
Self _____ Student's Spouse _____
EACH FIELD MUST CONTAIN A NUMERIC VALUE. ENTER $0, IF APPLICABLE.
