Fillable 2020-2021 Request for Review Dependent Student Income Reduction/Job (Butler University)

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2020-2021 Request for Review Dependent Student Income Reduction/Job (Butler University)

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The 2020-2021 Request for Review Dependent Student Income Reduction/Job (Butler University) form is 2 pages long and contains:

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2020-2021 Request for Review
Dependent Student
Income Reduction/Job Loss
______________________________________________________________ _____________________________________________
Student’s Name
Student’s ID
New to Butler University for the 2020-2021 academic year. Currently enrolled at Butler University.
Complete this information if a significant loss of income is projected which results in restricting your parents’ ability to
contribute to your education. Special circumstances are defined as situations that the family has minimal control over: death,
disability, loss of income due to lay-off, and unemployment. Voluntary circumstances (consumer debt, voluntary
leave of employment) are not eligible for consideration. You should continue to judge your ability to afford a Butler
education based on your original aid offer. Applications for loans and payment plans should not be delayed during the
processing of a special circumstance. Adjustments to financial aid eligibility will be reflected in Student Financial Planning (at
my.butler.edu under Academic Tools).
Step 1: Check reason for request for review
Loss or reduction of parent(s) income due to involuntary circumstances.
Reason for income loss: ________________________________________________________________
Dates of income loss (include month/day/year): ______________________ to _______________________
Are you receiving Unemployment Benefits? YES NO
If you are receiving Unemployment Benefits, please send a copy of your unemployment benefit statement to ensure
maximum consideration.
Loss of income due to parent death, separation, or divorce.
Step 2: Include/attach the following information to explain your situation
1. A written statement answering the question:
“How does this situation affect the parent’s ability to contribute financially to the student’s education?”
2. Documentation of the reason for requesting a review.
Examples: job termination notice, parent’s last pay stub, letter of unemployment, unemployment benefit
statement, salary reduction statement, etc.
Step 3: Provide Actual and Projected Income
Provide actual and/or projected income for the annual 2019 tax year and monthly income for the 2020 calendar year to the best of
your ability based on your financial situation today.
All wages reported should be gross wages – the amount earned before taxes and deductions.
Do not leave any boxes blank. Use “0” or “n/a” as appropriate.
Actual and Projected Income
Annual Totals
Gross Wages
Parent 1
Gross Wages
Parent 2
Unemployment
Benefits
*Other Income
Source:
**Pre-Tax
Retirement
Contributions
Child
Support
Received
2019 Totals
$
$
$
$
$
$$
$
Monthly
Totals
Gross Wages
Parent 1
Gross Wages
Parent 2
Unemployment
Benefits
*Other Income
Source:
Child
Support
Received
Jan 2020
$
$
$
$
$
Feb 2020
$
$
$
$
$
March 2020
$
$
$
$
$
April 2020
$
$
$
$
$
May 2020
$
$
$
$
$
June 2020
$
$
$
$
$
July 2020
$
$
$
$
$
August 2020
$
$
$
$
$
Sept 2020
$
$
$
$
$
Oct 2020
$
$
$
$
$
Nov 2020
$
$
$
$
$
Dec 2020
$
$
$
$
$
2020 Totals
$
$
$
$
$
*Other Income examples: alimony, death benefits, severance pay, early retirement pay, retirement incentives, housing
allowances, payments made on your behalf
**Pre-Tax Retirement Contributions: 401K, 403B, IRA and SEP
Step 4: Sign and return this form and requested information to the Office of Financial Aid
Preferred method is email to finaid@butler.edu. You may also fax to 317.940.8250 or mail this form to the Office of Financial
Aid, Butler University, 4600 Sunset Ave, Indianapolis, IN 46208.
Signature
By signing below, we certify the information provided is correct. We understand that verification of the accuracy of
these estimates may be requested at a later date.
_____________________________________________________________ _________________________________
Student’s Signature Date
_____________________________________________________________ _________________________________
Parent’s Signature Date
_____________________________________________________________ _________________________________
Parent’s Email Daytime Phone Number
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2020-2021 Request for Review Dependent Student Income ReductionJob (Butler University)

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Completed 18 August 2020

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