REQUEST FOR FINANCIAL AID AWARD REVIEW
2019-20
Student’s Name Student’s ID
Student’s Address
Student’s Email Student’s Phone
Parent’s Name Parent’s Day Phone
Parent’s Email
Situations may occur that affect your eligibility for federal funds. Please complete this form to document
those situations. A committee within the Office of Student Financial Assistance will review your request.
Decisions are based on the documentation provided and the guidelines established by Jacksonville
University and federal regulations. All decisions of the committee are final. Your request for re-evaluation
will not be reviewed until we receive all of the required documentation. Please allow 2-6 weeks after
receipt for review and evaluation.
Award reviews may be requested at any time resulting from a change in family circumstance(s). Check only
those that are applicable to your family’s specific situation and submit supporting documentation with this
form.
Involuntary loss/reduction of work income
Loss of unemployment or some untaxed income or benefit.
Household’s unusually high unreimbursed medical or dental expenses (must exceed 10% of AGI)
Legal separation/divorce
Death of a parent/spouse
Any other information or changes affecting your family’s financial situation
Please use this section to provide additional information describing the basis for your request. You may attach
additional letters or documents that you think will support your request.
CERTIFICATION
By signing below, I certify that the information contained on this form is true and complete to the best of my
knowledge. Upon request, I will provide any additional documentation to substantiate the information provided.
Student Date
Parent Date
Please list anticipated income for 2019 below. For any request for review, verification must be
completed. Please submit signed copies of your 2017 Federal Tax Return Transcript, including
all Schedules and W2’s, if not already submitted. It is helpful to use your tax returns and W2’s
when completing this form. Complete the V-1 Verification Worksheet available at
http://www.ju.edu/financialaid/forms.php
ESTIMATED TAXABLE INCOME
2019
Father’s taxable wages on projected tax return
Mother’s taxable wages on projected tax return
Student taxable wages on projected tax return
Spouse taxable wages on projected tax return
Interest and dividends
Rental/business/capital losses
Rental/business/capital gains
IRA/Pension: (total rollover)
Unemployment compensation
Other (source: )
TOTAL INCOME
$
Less IRA, Keogh and self-employed SEP and SIMPLE
plans
-
Less any other adjustments to income
-
ADJUSTED GROSS INCOME
$
ESTIMATED TAXABLE/UNTAXABLE INCOME
2019
Pre-tax pension contributions
IRA/Keogh payments
Tax-exempt interest/dividends
Housing/living allowance
Worker’s Compensation
Child Support
Social Security (for all family members)
Other: (source: )
REQUIRED SUPPORTING DOCUMENTATION
2017 Federal tax return transcript for student
2017 Federal tax return transcript for parent(s)
Involuntary Loss/Reduction of Work Income (at least 3 months)
Termination Letter
Unemployment compensation letter stating weekly payment and term of eligibility (i.e. $200
per week for 26 weeks, beginning October 1, 2017)
Year to date earnings from terminated job, i.e. last pay stub
Year to date earnings from spouse’s job, i.e. last pay stub
Severance paperwork (payment made by employer at the time of or extended timeframe by the
employer)
Involuntary Loss of Unemployment or some Untaxed Income or Benefit
State of unemployment expiration dated within the base year
Excessive medical bills exceeding 10% of the family’s AGI, not included on taxes.
Copies of billings not covered by insurance, not included on taxes, and PAID by tax filer
within the year of tax filing
Death of parent or student’s spouse
Death certificate
Year to date earnings of deceased, i.e. last pay stub
FOR OFFICE USE ONLY: Approved Denied
Adjustments
Counselor Signature Date
Director Signature Date