Fillable 2019-2020 Petition for Consideration of Special Circumstances (Anoka Technical College)

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2019-2020 Petition for Consideration of Special Circumstances (Anoka Technical College)

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Financial Aid Office
1355 West Highway 10
Anoka, MN 55303
Phone: 763 – 576 –7730
Fax: 763-576-7721
2019-2020 Petition for Consideration of Special Circumstances
Name _________________________________________ Stu.ID _________________________
Deadline for submission of Income Review of Special Circumstance applications must be received within the semester the student is enrolled at ATC,
and no later than two weeks from the end of the enrolled semester.
THE STUDENT MUST COMPLETE AND SUBMIT this signed document, complete the Projected 2020 Income Chart, along with the Requested
Documentation as detailed below:
Change of Income. (Please circle which year change occurred in and submit the required documents for that year).
2019 2020
Requested Documentation: Requested Documentation:
• Letter from you (spouse/parents if applicable) addressing • Letter from you (spouse/parents if applicable) addressing
and comprehensively describing the situation. and comprehensively describing the situation.
• 2019 Federal Tax Return Transcript, all 2019 W-2’s • Last three 2020 pay stubs.
Complete the Untaxed Income Chart.
Lay Off (Please do not submit appeal if receiving unemployment benefits until after 10 weeks).
Requested Documentation:
• Letter from you (spouse/parents if applicable) addressing and comprehensively describing the situation.
• Letter from employer indicating effective date and any severance benefits.
• Statement from Unemployment Office outlining benefits.
• Final pay stub from laid off position.
Three most recent pay stubs of all other current positions (spouse/other parent if applicable).
Major Medical or Dental Expenses NOT Covered by Insurance.
Requested Documentation:
• Letter from you (spouse/parents if applicable) addressing and comprehensively describing the situation.
• Proof of your expenses paid such as your tax return itemized medical or dental deductions page or receipts of payments made.
Retirement
Requested Documentation:
• Letter from employer documenting retirement date and benefits received.
• Final pay stub for retiree.
• Last three pay stubs for parent/spouse who is still working.
Separation, Divorce, or Death. Since filing the FAFSA, you (parents if applicable) have become separated or divorced, or a
spouse (parents if applicable) has died.
Requested Documentation:
• Letter from you (spouse/parents if applicable) addressing and comprehensively describing the situation.
• Legal separation papers, divorce decree, or death certificate.
• Federal Tax Return Transcript and all W-2’s for the year separation, divorce or death occurred.
Other Unusual Circumstances.
Requested Documentation:
• Letter from you (spouse/parents if applicable) addressing and comprehensively describing the situation.
• Sufficient and appropriate supporting documentation.
Anoka Technical College and Anoka-Ramsey Community College are affirmative action, equal opportunity educator/employers. To receive this information in an alternative format, 763-576-4069. Rev. 2/20
Student (and spouse)
Untaxed Income Chart
Calendar Year 2019
Do not leave any box blank. If the answer is zero, enter $0.
Parent(s)
$
Payments to tax-deferred pension and savings plans (paid directly or withheld from
earnings), including but not limited to, amounts reported on the W-2 Form in Boxes
12a through 12d, codes D,E,F,G,H,and S
$
$
Child support RECEIVED for all children. Don’t include foster care or adoption
payments.
$
$
Housing, food, and other living allowances paid to members of the military, clergy, and
others (including cash payments and cash value of benefits)
$
$
Veterans’ non-education benefits such as Disability, Death Pension, or Dependency &
Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances
$
$
Any other untaxed income or benefits not reported elsewhere
$
$
Money received, or paid for you on your behalf (e.g., bills), not reported elsewhere on
this form
XXXXXXXXXX
$
Child support PAID because of divorce or separation or as a result of a legal
requirement.
$
Anoka Technical College and Anoka-Ramsey Community College are affirmative action, equal opportunity educator/employers. To receive this information in an alternative format, 763-576-4069. Rev. 2/20
Projected 2020 Income Chart - Please include the total amounts that you and your parents/spouse have received/earned and expect to receive/earn in
2020. (FULL YEAR TOTALS). Do not leave items blank; enter “0” where appropriate.
St
udent Parents/Spouse
Taxable Wages $________________ $________________
Unemployment Compensation $________________ $________________
Severance Pay $________________ $________________
IRA/Pension Distribution $________________ $________________
Disability Income $________________ $________________
Interest and Dividend Income $________________ $________________
Food/Housing/Living allowance $________________ $________________
Worker’s Compensation $________________ $________________
Other income (list source): _____________________________ $________________ $________________
**
* The review of your appeal will be delayed if ALL documentation has not been received. Additional documents may be requested upon
initial review of appeal.***
***I
certify that all of the information stated in the letters attached concerning my request for a status change is true and complete.***
_________
______________________________ _______________________________________________
Signature (student) Date Parent’s Signature (if dependent student) Date
_ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
OFFICE USE ONLY
Approved: __________________________________________________________________________________________________________
**
*If approved, your revised award letter will soon be available online through eServices at www.AnokaTech.edu
. You will need your StarID and
password. Award Letters are not mailed. Please Note: Eligibility for additional grant aid can reduce student loan funds. *** The review of your appeal will
be delayed if ALL documentation has not been received.***
EF
C w/ Verification ________ EFC w/ Petition ________
Pending/Denied: _______________________________________________________________________________________________________
_________________________________________________________________________________________________________________
__________________________________________ ____________________
Financial Aid Administrator Date
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2019-2020 Petition for Consideration of Special Circumstances (Anoka Technical College)

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Completed 18 September 2020

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