Fillable 2020-2021 Re-evaluation of Financial Aid Form (Randolph-Macon College)

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2020-2021 Re-evaluation of Financial Aid Form (Randolph-Macon College)

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____________________________ _______________________ _____ _______________
_____________________________________________________________________________________
_____________________________________________________________________________________
Office of Financial Aid
P. O. Box 5005, 114 College Avenue
Ashland, VA 23005
FAX: (804) 752-3719
Email: financial-aid@rmc.edu
2020-2021 Re-evaluation of Financial Aid Form
Student’s Last Name First Name MI R-MC ID#
Randolph-Macon College is committed to providing need-based assistance to qualifying students. The Financial
Aid office recognizes that some families experience changes that are not reflected on the Free Application for
Federal Student Aid (FAFSA). Please note that no request for a re-evaluation will be considered without a
FAFSA and that submission of this form does not guarantee any adjustment to a student’s aid package.
All students requesting a re-evaluation must follow the same process. There are no exceptions. This will help
us assure all of those who apply for or receive assistance from R-MC that we are fair and principled in our
approach.
Families must demonstrate how the reason for the request will affect their family’s ability to contribute toward
the student’s educational costs. Please submit all documentation and as much explanation as possible. Forms
submitted without documentation will not be reviewed.
SECTION I
Please check the appropriate box(es) concerning your reason(s) for requesting a re-evaluation of assistance:
❑ ____ Mother ____ Father has become ____ unemployed, ____ retired, ____ separated, or ____ has
experienced a reduction in earnings for the period of January 1, 2019 to December 31, 2019. Please
complete Section II (providing details of the change, termination date, separation date, reduction date,
etc., as well as expectation of future employment) Section III, Section VI, and Section VII.
The date of this change was _____________________________.
❑ Un-reimbursed medical expenses are impacting the family’s ability to contribute. Please complete
Section II (explaining the diagnosis and the treatment required) Section IV, Section VI and Section VII.
Attach documentation of the medical condition(s) and un-reimbursed costs related to that condition(s).
Only expenses related to the medical condition will be considered.
❑ Death of parent whose information was reported on the FAFSA. Please complete Section III, Section
V, Section VI and Section VII.
❑ Other: Complete Section II, Section VI and Section VII and provide the relevant documentation.
SECTION II
Explanation of Circumstances (Please be specific and attach an additional sheet or use the other side of this
page, if necessary):
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____________________________ _______________________ _____ _______________
Student’s Last Name First Name MI R-MC ID#
SECTION III
Financial aid for 2020-2021 is based on financial information as submitted on the FAFSA, which requires
calendar year income information. Aid may be adjusted if you anticipate that your 2019 income will be
significantly less than 2018 income. Please submit the last pay stub, unemployment benefit statement,
termination notification, etc., to document and support the revised information. You must also submit a copy of
your 2018 Federal Income Tax transcript, which you may request at
2018
www.irs.gov to have it mailed to you or by
calling IRS at 1-800-908-9946, AND 2018 W-2 Statement(s), if you have not already done so. If you have
completed your FAFSA using the IRS Data Retrieval Tool, it will not be necessary to submit a transcript of
your return. We will not review any requests for which documentation is not submitted.
(Please indicate “as of” date in the spaces provided in the column headings below)
Taxable Income
Actual
Income
(Jan. 1, 2019
- ________)
Estimated
Income
(__________ -
Dec. 31, 2019)
Total Projected
2019 Income
(Actual Income +
Estimated Income)
Father/Step-father Wages, Salaries, Compensation from
Work (Provide Gross Amount)
Mother/Step-mother Wages, Salaries, Compensation from
Work (Provide Gross Amount)
Interest and Dividend Income
Net Income/Loss from Business and /or Farm (Reported
on Schedule C, E, and/or F)
Severance Pay
Vacation or Sick Pay
Stock Options
Capital Gain/Loss
Rental Income/Loss
Taxable Social Security Benefits
Alimony Received
Unemployment Compensation
Pensions/Annuity/IRAWithdrawals
Income from Royalties, Partnerships, Estates and Trusts
Untaxed Income
Total Child Support that You Received for all children
Contributions to Retirement Plans
Housing Allowance
Other Untaxed Income
Expenses
Total Child Support that You Paid to another household
Alimony Paid to another
Family household size: ________ (Include yourself; your
parent(s); and your siblings and others, if your parents
provide more than half of their support).
Number of children in college: ____ (Include only those
dependent children who will attend at least half-time in
2020-2021 in a program that leads to an undergraduate
college degree or certificate).
2 of 4
____________________________ _______________________ _____ _______________
Student’s Last Name First Name MI R-MC ID#
SECTION IV
Families may experience unusually high un-reimbursed medical expenses due to specific medical conditions.
Our policy is to evaluate the expenses associated with the medical condition(s) to determine if any adjustment
can be made.
Below, please provide a monthly, out of pocket cost breakdown for 2018 for the medical treatment(s) for the
condition(s) described in Section II.
2018 Treatment Costs Hospitalization Costs Medication Costs
January
February
March
April
May
June
July
August
September
October
November
December
Please attach documentation of the diagnosis and the specific un-reimbursed medical expenses related to the
diagnosis. How much of the total un-reimbursed medical expenses are you paying each month or have paid?
$__________, per month $__________, amount fully paid
SECTION V
Please provide the following information regarding the death of a parent.
Date of Death: _______________________
Surviving Parent: _____ Father/Step-father _____ Mother/Step-mother
Please provide information and documentation on the following monies received:
Life Insurance Policy(s): $
Death Benefits: $
Taxable Social Security Insurance Benefits: $
Other (please explain): $
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____________________________ _______________________ _____ _______________
__________________________________ ______________________
__________________________________ ______________________
__________________________________ ______________________
_________________________________ ___________________ ____________________
Student’s Last Name First Name MI R-MC ID#
SECTION VI
Anticipated outside sources of aid available to the student during the 2020-2021 school year:
Pre-paid tuition and/or savings plans $________________________
Private scholarships $________________________
Other (do not list R-MC awards) $________________________
How much additional aid are you requesting? $________________________
What is the student’s intended career goal? _______________________________________
Are you eligible to receive Post 9/11 GI benefits?
SECTION VII
CERTIFICATION
Do not submit this application without copies of relevant documentation. We cannot review the
application without this information. Incomplete applications will not be reviewed.
We certify that all of the information reported in support of the student’s application for a re-evaluation of the
current financial assistance is complete and correct.
We understand that completing the Re-evaluation of Financial Aid Form does not guarantee any change to the
student’s existing aid package.
We also understand that any changes made to this year’s award are based on available resources and current
awarding policies. Any future changes may not result in an updated aid package.
(In the case of a divorced/separate family, only the signature of the custodial parent is required)
Student Signature Date
Mother/Stepmother Signature Date
Father/Stepfather Signature Date
If we have questions about this application or require additional documents, we may contact you. Please
provide information for the person we should contact:
Name Daytime Phone E-mail address
RETURN THIS REQUEST FORM AND SUPPORTING DOCUMENTATION TO THE FOLLOWING
ADDRESS:
Randolph-Macon College FAX: (804) 752-3719
Financial Aid Office OR E-Mail: financial-aid@rmc.edu
P. O. Box 5005
Ashland, VA 23005-5505
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2020-2021 Re-evaluation of Financial Aid Form (Randolph-Macon College)

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Completed 1 February 2021

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