ICC Financial Assistance Office
1 College Drive
East Peoria, IL 61635-
0001
Phone: (309) 694-5
600
Fax: (309) 694-
5160
email: financialaid@icc.edu
Revised April 16, 2020 KR Page 1
2020-2021 SPECIAL CIRCUMSTANCE
Student Name:
ICC Student ID:
PURPOSE: According to federal law, a family’s 2018 income is used to assess financial need for the 2020-2021 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 your parent(s) that have occurred and that will
severely limit the ability of your parent(s) to contribute toward your 2020-2021 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 signed 2019 tax return and W-2s must be attached.
Please check the categories that apply to the student/spouse/parent(s) and complete the Expected Income and Benefits Table.
Unemployment or change of employment: Student/Parent(s)/Spouse must have earned money in 2018, 2019, and lost job involuntarily
for at least 8 weeks in 2020.
Required Documentation
A signed copy of student’s and/or student’s spouse and/or your parent’s 2019 IRS Federal Tax Return, W-2’s and a copy of student’s
and/or student’s spouse, and/or your parent’s 2019 IRS tax transcript if they did not use the IRS retrieval on the FAFSA.
A signed copy of student’s and/or student’s spouse, and/or your parent’s 2019 IRS Federal Tax Return and W-2’s and a copy of student’s
and/or student’s spouse, and/or your parent’s 2019 IRS tax transcript.
Submit a copy of the letter of separation/termination or letter from student’s/spouse/ parent’s previous employer on company letterhead
stating effective date and the circumstances under which they left their employment.
Last or current paycheck stub showing 2020 year-to-date earnings for your parent(s) from each job worked in 2020.
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 Parent or Spouse
Required Documentation
Copy of death certificate
A signed copy of student’s spouse or parent’s 2018 IRS Federal Tax Return and W-2’s and a copy of student’s spouse or parent’s 2018
IRS tax transcript if they did not use the IRS retrieval on the FAFSA.
Signed copy of student’s spouse or parent’s 2019 IRS Federal Tax Return and W-2’s and a copy of student’s spouse or parent’s 2019 IRS
tax transcript
Divorce or Separation of Parent or Spouse
Required Documentation
Copy of separation or divorce decree (indicating date of separation/divorce), if legal documentation cannot be provided, spouse or parent
must submit a signed statement with the details of separation, living arrangements and date of separation.
A signed copy of student’s spouse or parent’s 2018 IRS Federal Tax Return and W-2’s and a copy of student’s spouse or parent’s 2018
IRS tax transcript if they did not use the IRS retrieval on the FAFSA.
A signed copy of student’s spouse or parent’s 2019 IRS Federal Tax Return and W-2’s and a copy of student’s spouse or parent’s 2019
IRS tax transcript
Medical and dental expenses that exceed 12% of your parent’s or spouse's total income
Required Documentation
2018 1040 Schedule A
Provide copies of cancelled checks or paid receipts for expenses paid in 2018 that were not reimbursed by insurance.
A signed copy of your parent’s 2018 IRS Federal Tax Return and W-2’s and a copy of your parent’s 2018 IRS tax transcript if they did not
use the IRS retrieval on the FAFSA.
A situation you feel warrants consideration for special circumstances (loss of a benefit; i.e. child support, social security for a
surviving dependent, unemployment, disability, workman’s comp, or other)
Required Documentation
Provide written explanation and supporting documentation
A signed copy of student’s and/or student’s spouse and/or your parent’s 2018 IRS Federal Tax Return and W-2’s and a copy of student’s
and/or student’s spouse and/or your parent’s 2018 IRS tax transcript if they did not use the IRS retrieval on the FAFSA.
A signed copy of student’s and/or student’s spouse and/or your parent’s 2019 IRS Federal Tax Return and W-2’s and a copy of student’s
and/or student’s spouse and/or your parent’s 2019 IRS tax transcript.
Revised April 16, 2020 KR Page 2
EXPECTED TOTAL INCOME AND BENEFITS TABLE: January 1, 2020 through December 31, 2020
WAGES FROM WORK FOR STUDENT/SPOUSE/PARENT(S)
(If it does not apply enter “0” or “N/A”)
Actual Income from
1/1/2020 to today
Estimated Income from
today to 12/31/2020
Student Gross Wages (provide most recent pay statement)
Spouse Gross Wages (provide most recent pay statement)
Parent 1 Gross Wages (provide most recent pay statement)
Parent 2 Gross Wages (provide most recent pay statement)
OTHER TAXABLE INCOME
Unemployment Gross Income to date and anticipated in 2020
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 2020 Federal Tax return)
Business Income, Rents, royalties and/or annuities
Maintenance/Support received in 2020 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 form; you may be fined, be sentenced to jail, or both.
ICC Student ID:
Student Signature (Required)
Date
Parent of Dependent Student Signature (Required)
Date
Student’s Spouse 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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