Fillable 1920 Special Conditions 2 (Northwest State Community College)

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1920 Special Conditions 2 (Northwest State Community College)

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U.S.A. forms for Northwest State Community College

BROWSE NORTHWEST STATE COMMUNITY COLLEGE FORMS

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Student Name: ___________________________________ NSCC ID number: N________________________
Email Address: ___________________________________________ Date of Birth: _____/_____/_____
Financial need is, in part, based on each student’s or families’ gross annual income from the 2017 tax year. If your income has recently
decreased or you have an unforeseen financial hardship that was not taken into account on your Free Application for Federal Student Aid
(FAFSA), we may be able to re-evaluate your financial need based on your projected gross income for the 2019 tax-year (January 1, 2019 –
December 31, 2019). Please remember that not all special circumstance recalculations will result in additional financial aid and allow
up to 6 weeks for the financial aid office to review your request.
INSTRUCTIONS: For the rest of this form, if you are dependent, you must provide information for yourself and your parent(s). If you are
an independent student, you must provide information for yourself and your spouse (if married). Complete all sections and attach required
documentation. Please complete Steps 1-3.
STEP #1
Are you (or your spouse/parents) receiving any of the following? Check all that apply:
_____SSI _____Food Stamps _____Free/Reduced Lunch _____TANF _____WIC _____Medicaid
Are you (or your spouse/parents) a dislocated worker? _____Yes _____No
If you (or your spouse/parent) have quit your job you are not considered a dislocated worker
STEP# 2
Complete the chart below estimating all income for the 2019 calendar year. (January 2019 - December 2019).
Student (include spouses income)
Parent (include both parents)
Adjusted Gross Income
Income from work
$______________________
$______________________
Unemployment
$______________________
$______________________
Taxable Social Security
$______________________
$______________________
Other taxable income (explain)___________
$______________________
$______________________
Untaxed Income
Payments to tax deferred pensions
$______________________
$______________________
IRA deductions
$______________________
$______________________
Child Support
$______________________
$______________________
Untaxed portions of IRAs or pensions
$______________________
$______________________
Workman’s Compensation
$______________________
$______________________
Disability
$______________________
$______________________
Other Untaxed Income (explain)___________
$______________________
$______________________
Total Cash Savings and Checking
$______________________
$______________________
All of the information provided by me, or any other person, is true and complete to the best of my knowledge. If asked by an authorized official,
I agree to give proof of the information that I have given on this form. I realize that underestimating projected income could result in reduced
eligibility, repayment of aid, or both. I further understand that purposely giving false or misleading information may subject me to fines and/or
other penalties.
_____________________________________________ __________________________
Student’s Signature Date
_____________________________________________ __________________________
Parent’s Signature (if parent special condition) Date
Northwest State Community College does not discriminate on the basis of race, color, national origin, sex, gender identity, disability, religion or age
in its programs or activities.
2019-2020 Special Condition
Northwest State Community College • 22600 State Route 34 • Archbold • OH • 43502
Phone: 419-267-1333 • Fax 419-267-5587 • finaid@northweststate.edu
2
STEP #3 - Please check the circumstance which applies and provide the additional information that is requested for
each situation. The requested documentation must be attached to this form when returned to the Financial Aid Office.
_____a) Unemployment, reduced employment or job change.
Student/Spouse/or Parent must be unemployed for at least 10 weeks in 2019.
Typed letter explaining your special circumstance. Please make sure to sign and date your letter.
Last check stub(s) from previous employer
Letter from previous employer stating the date of termination
Benefit or denial letter of unemployment
Check stub of new employment or statement regarding employment status
2017 Federal Tax Transcript (request at www.irs.gov) or signed 2017 Form 1040
W-2 for 2017- student/spouse (independent student) or mother/father
(dependent student)
Dependent/Independent Verification Group V1 worksheet
_____b) Separation or Divorce
Typed letter explaining your special circumstance. Please make sure to sign and date your letter.
Court documentation verifying legal separation or divorce
Statement of any child support received for the dependent children or child support paid to children
not living in your home.
2017 Federal Tax Transcript (request at www.irs.gov) or signed 2017 Form 1040
W-2 for 2017- student/spouse (independent student) or mother/father (dependent student)
Dependent/Independent Verification Group V1 worksheet
_____c) Death of a Parent or Spouse
Typed letter explaining your special circumstance. Please make sure to sign and date your letter.
C Copy of a death certificate, obituary notice, or printed memorial program.
Statement of how the deceased is related to the student (may include in letter)
2017 Federal Tax Transcript (request at www.irs.gov) or signed 2017 Form 1040
W-2 for 2017- student/spouse (independent student) or mother/father (dependent student)
Dependent/Independent Verification Group V1 worksheet
_____d) Unusual Medical or Dental expenses paid but not covered under insurance
Total expenses
paid
must be more than 11% of your AGI. (The EFC calculation accounts for 11% of your
income to be used to pay medical/dental bills)
Typed letter explaining your special circumstance. Please make sure to sign and date your letter.
C Copy of Medical or Dental bills that were paid in 2019 that were not paid by a third party.
Include in letter, Total amount of debt or expense and explanation of hardship
Proof of payment of Medical or Dental bills without insurance coverage
2017 Federal Tax Transcript (request at www.irs.gov) or signed 2017 Form 1040
W-2 for 2017- student/spouse (independent student) or mother/father (dependent student)
Dependent/Independent Verification Group V1 worksheet
_____e) Other -- You have a situation you would like to have reviewed; ex: Retirement, Reduced or
Terminated Untaxed Income, Liquidation/Foreclosure, Unusual Debt or Expenses.
Typed letter describing any changes in financial circumstances and explain how it has affected the ability
of you and/or your family to contribute to your education. Make sure to sign and date your letter.
2017 Federal Tax Transcript (request at www.irs.gov) or signed 2017 Form 1040
W-2 for 2017- student/spouse (independent student) or mother/father (dependent student)
Dependent/Independent Verification Group V1 worksheet
Other supporting documentation
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1920 Special Conditions 2 (Northwest State Community College)

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Completed 3 October 2020

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