ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5311
Fax: (309) 694-5160
email: financialaid@icc.edu
Rev. March 14, 2019
2019-2020 Independent Special Circumstance
Student Name (please print)
ICC Student ID #
PURPOSE: According to federal laws, a family’s 2017 income is used to assess financial need for the 2019-2020 aid year. If the family’s 2019
calendar year income is lower due to a special circumstance, a financial aid administrator may be able to use the 2019 income to assess financial
need. Please complete this form to assist you in reporting changes in the financial circumstances of you and/or your spouse that have occurred and
that will severely limit the ability of your and/or your spouse to contribute toward your 2019-2020 college costs.
IF THIS FORM IS NOT FILLED OUT COMPLETELY AND IF ALL THE INFORMATION IS NOT SUBMITTED THIS FORM WILL
NOT BE PROCESSED. If this form is submitted after January 1, 2020, a 2019 tax transcript and W-2s must be attached.
Please check the categories that apply to the student/spouse and complete the Expected Income and Benefits Table.
Unemployment or change of employment: Student/Spouse must have earned money in 2017 and lost his/her job involuntarily
for at least eight weeks in 2019.
Required Documentation
A signed copy of your and/or your spouse’s 2017 IRS Federal Tax Return and W-2’s and a copy of your 2017 IRS tax transcript if they did not
use the IRS retrieval on the FAFSA.
A signed copy of your and/or your spouse’s 2018 IRS Federal Tax Return and W-2’s and a copy of your 2018 IRS tax transcript
Submit a copy of the letter of separation/termination or letter from your previous employer on company letterhead stating effective date and the
circumstances under which you or your spouse left their employment.
Last or current paycheck stub showing 2019 year-to-date earnings for both student and spouse from each job worked in 2019.
Unemployment benefit summary stating the last day worked
Verification of unemployment and amounts of unemployment benefits received
Verification of disability and amount of benefits received.
Death of a spouse
Required Documentation
Copy of death certificate
A signed copy of your and/or your spouse’s 2017 IRS Federal Tax Return and W-2’s and a copy of your 2017 IRS tax transcript if you did not
use the IRS retrieval on the FAFSA.
A signed copy of your and/or your spouse’s 2018 IRS Federal Tax Return and W-2’s and a copy of your 2018 IRS tax transcript
You and your spouse have separated or divorced.
Required Documentation
Copy of separation or divorce decree (indicating date of separation/divorce), if legal documentation cannot be provided, student must submit a
signed statement with the details of separation living arrangements and date of separation.
A signed copy of your and/or your spouse’s 2017 IRS Federal Tax Return and W-2’s and a copy of your 2017 IRS tax transcript if you did not
use the IRS retrieval on the FAFSA.
A signed copy of your and/or your spouse’s 2018 IRS Federal Tax Return and W-2’s and a copy of your 2018 IRS tax transcript
Medical and dental expenses that exceed 12% of your total income
Required Documentation
2017 1040 Schedule A
Provide copies of cancelled checks or paid receipts for expenses paid in 2017 that were not reimbursed by insurance.
A signed copy of your and/or your spouse’s 2017 IRS Federal Tax Return and W-2’s and a copy of your 2017 IRS tax transcript if you did not
use the IRS retrieval on the FAFSA.
A situation you feel warrants consideration for special circumstances (loss of a benefit; e.g. child support, social security for a
surviving dependent, unemployment, disability, workers comp, or other)
Required Documentation
Provide written explanation and supporting documentation
A signed copy of your and/or your spouse’s 2017 IRS Federal Tax Return and W-2’s and a copy of your 2017 IRS tax transcript if you did not
use the IRS retrieval on the FAFSA.
A signed copy of your and/or your spouse’s 2018 IRS Federal Tax Return and W-2’s and a copy of your 2018 IRS tax transcript.
Rev. March 14, 2019
EXPECTED TOTAL INCOME AND BENEFITS TABLE: January 1, 2019 through December 31, 2019
WAGES FROM WORK FOR STUDENT AND SPOUSE
(If it does not apply enter “0” or “N/A”)
Estimated Income
from today to
12/31/2019
Student gross wages (provide most recent pay statement)
Spouse gross wages (provide most recent pay statement)
OTHER TAXABLE INCOME
Unemployment Gross Income to date and anticipated in 2019
Severance, paid time off or vacation pay out (if not included in gross wages)
Social Security Income (provide gross monthly statement)
Taxable Disability Income (provide gross monthly statement)
Taxable Pension (provide gross monthly statement)
Interest/Dividend Income (please anticipate any type of asset income you are required to
report on your 2019 Federal Tax return)
Business income, rents, royalties and/or annuities
Maintenance/support received in 2019 if separated/divorced
Taxable income from 401K disbursement or other existing assets (include year to date gross
disbursements and anticipated disbursements)
Other taxable income such as survivor benefits, lump sum payout, etc.
List the source:
TYPES OF UNTAXED INCOME
Housing allowance for military or clergy (Contract or LES statement)
Workers' Compensation (provide gross monthly statement)
Untaxed disability income (provide gross monthly statement)
Child support received for all members of your household
Untaxed pension (provide gross monthly statement)
Other untaxed income (list the source)
Written explanation of circumstances: (if additional space is needed please attach another sheet of paper with your name and
your ICC student ID number listed at the top)
I certify that the information provided on this form and the
attachments are true and complete to the best of my
knowledge.
FEDERAL WARNING: If you purposely give false or
misleading information on this worksheet, you may be fined,
be sentenced to jail, or both.
Student Signature (Required)
Date
Spouse's Signature (Optional)
Date
It is the policy of this College that no person, on the basis of race, color, religion, gender, national origin, age, disability,
sexual orientation, or veteran’s status, shall be discriminated against in employment, in educational programs and
activities, or in admission. Inquiries and complaints may be addressed to the Compliance Officer, Diversity Department.
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