Fillable 2019-2020 INCOME ADJUSTMENT FORM O FFICE OF FINANCIAL (CUNY Kingsborough Community College)

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2019-2020 INCOME ADJUSTMENT FORM O FFICE OF FINANCIAL (CUNY Kingsborough Community College)

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O
FFICE OF FINANCIAL AID
2019-2020 INCOME ADJUSTMENT FORM
Kingsborough Community College (KBCC) recognizes that special circumstances may occur after the Free Application
for Federal Student Aid (FAFSA) was completed, which may affect a student’s eligibility for Federal financial aid. If you,
your spouse or parent(s) have experienced a significant decrease in income since 2017 due to one of the conditions
described on this form, you may be eligible for an Income Adjustment. Please complete Sections A of this form and
submit it to our Office with the required documents as indicated for each category.
All requests for an Income Adjustments MUST be submitted with the Tax Return Transcript(s) of the Student
and/or parent(s) & W2(s.)
_____________________________________
__________________________________
________________________
Last Name
First Name
EMPLID #
This form is being completed based on (a) special circumstance(s) experienced by the:
Student
Parent(s)
Section A. Please review the selections below and check the box/es that apply/ies to you.
Check Reason
Loss or reduction of
Income
2019-2020 Income Adjustment Form.
Copy of 2017 Tax Return Transcript and W2s for student/spouse and/or parent(s.)
Copy of last paystub(s) from former employer(s) and current employer if applicable.
Detailed statement explaining your circumstances.
Termination letter from former employer.
Copy of unemployment compensation Letter
.
C
opy of DD214 if appeal is due to discharge from active military duty
Disability
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances.
Copy of 2017 Tax Return Transcript and W2s for student/spouse and/or parent(s.)
Proof of Disability Compensation
Loss of Untaxed Income
(SSI, Child Support etc.)
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances.
Documentation from the agency reflecting the monthly amount along with t
he
ter
mination dat
e.
Divorce/Separation
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances.
Divorce/separation occurred after FAFSA was completed (submit divorce decree, proof
of legal separation or separate households.)
Copy of 2017 Tax Return Transcript and W2s for student/spouse and/or parent(s.)
*** NOTE: In the case of separation, proof of separate residence is required. At least two (2)
Utility billing statements for each person must be submitted to complete this review or a copy of
two separate leases.
Death
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances.
Copy of 2017 Tax Return Transcript and W2s for student/spouse and/or parent(s.)
Excessive medical/dental
expenses
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances.
Copy of 2017 Tax Return Transcript and W2s for student/spouse and/or parent(s.)
Copy of the Schedule A from original Tax Return(s.)
*** NOTE: Excessive medical and/or dental expenses should have been claimed on your 2017
Tax Return Transcript (s.) In the event this was not possible, attach billing statements, receipts,
etc.
Excessive Property
loss/damaged due to a
declared natural disaster
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances.
Copy of 2017 Tax Return Transcript and W2s for student/spouse and/or parent(s.)
Insurance claim forms and/or FEMA applications and any other relevant documents.
Roth IRA Conversion
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances.
Copy of 2017 Tax Return Transcript and W2s for student/spouse and/or parent(s.)
Proof of payment and an itemized statement showing funds usage. (Receipts,
cancelled checks, etc.)
Documentation reflecting the source of the income.
*** NOTE: Only apply for this adjustment if you converted a traditional IRA into a Roth IRA.
Other
2019-2020 Income Adjustment Form.
Detailed statement explaining your circumstances and supporting documents
.
Certification and Signature(s)
By signing this form, you certify that all of the information you provided is true and complete to the best of your knowledge and you
agree, if asked, to provide information that will verify the accuracy of your completed form.
Student’s Signature:
______________________________________
Date:
___________________
Parent’s Signature:
______________________________________
Date:
___________________
Approved
Denied
FAA Signature:
________________________________________
Date:
_____________________
Reason for granting/denying request for Income Adjustment:
For Administrative Use Only
For Administrative Use Only
Received By:
__________
Date:
___________
Processed By:
__________
Date:
___________
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2019-2020 INCOME ADJUSTMENT FORM O FFICE OF FINANCIAL (CUNY Kingsborough Community College)

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Completed 21 September 2020

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