Complete this form if you have experienced a change in your income and you would like the Financial Aid Office to consider this change
when reviewing financial aid eligibility. Please complete every section. If something does not apply to you, please indicate N/A or $0.
Are you or your spouse (if applicable) a dislocated worker/displaced homemaker? ................ NO YES
A dislocated worker/displaced homemaker is defined as a person who:
is receiving unemployment benefits due to being laid-off or losing a job, and
is unlikely to return to a previous occupation
has been laid-off or received a lay-off notice from a job
was self-employed, but is now unemployed due to economic conditions or natural disaster
previously provided unpaid services to the family (i.e., a stay-at-home parent), is no longer supported by their spouse/partner, is
unemployed or underemployed, and is having trouble finding or upgrading employment
Source(s) of Income
2020-2021 Income
(July 1, 2020 June 30, 2021)
Earnings from work by Parent 1/Student (_____________________________________)
Earnings from work by Parent 2/Student Spouse (_____________________________________)
Interest/dividend income
Net profit from business/farm (do not include losses)
Other taxable income (select: unemployment, rental income, alimony, pensions, annuities,
capital gains, royalties, estates, partnerships, trusts, severance payments, etc.)
Other untaxed income (select: disability benefits, social security benefits, supplemental security
income, welfare benefits, workman’s compensation, cash support from others, child support, etc.)
In order to fully review your request we also require all of the following:
1. A written explanation outlining the reason(s) for the change to your income. Please provide details that will help our office understand
your financial situation.
Statement attached? NO YES
2. Documentation that substantiates the change to your income (i.e. lay-off notice, unemployment benefits, death certificate, etc.)
Documentation attached? NO YES
3. A copy of your 2019 tax return (with all schedules and statements). If your tax return is not available at the time you complete this form,
please submit it as soon as it is available. We will not be able to fully review your request without your 2019 tax return.
I certify that all information reported on this form and any attachments and subsequent information provided to the Occidental College
Financial Aid Office is true, complete, and accurate to the best of my knowledge. I understand that if it is determined that I purposely
provided false or misleading information in an effort to receive federal financial aid, I may be fined, sentenced to jail, or both. This will also
be cause for referral (of the student) to the Judicial Council for possible violations of the Occidental College Code of Student Conduct.
The student and parent(s) may also be referred to the U.S. Department of Education Inspector General.
Parent Signature (no electronic signatures) Print Name Date
2019 tax return attached? NO
Phone: 323-259-2548
Fax: 323-341-4961
Occidental College
Financial Aid Office
1600 Campus Road F-35
Los Angeles, CA 90041
Please report all sources of income that you will/may receive from all sources for the 2020-2021 academic year. Please provide estimates
to the best of your ability. Forms completed entirely with zeros will not be considered.