Fillable 2020-2021 Special Circumstances Appeal Form (Lehigh Carbon Community College)

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2020-2021 Special Circumstances Appeal Form (Lehigh Carbon Community College)

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OFFICE OF FINANCIAL AID
4525 Education Park Drive, Schnecksville, PA 18078
P 610.799.1133 | F 610.799.1798
E finaid@mymail.lccc.edu
2020-2021 Special Circumstances Appeal Form
Student Name Student ID
Purpose
The 2020-2021 FAFSA takes into account 2018 tax year income. If your family’s current financial situation is
drastically different then it was in 2018, you may wish to consider submitting this form. Upon review, the Financial
Aid Office may deem it appropriate for your FAFSA information to be adjusted to be more equitable and
representative of your current financial situation.
Instructions
Complete sections 1 through 3 and ALL required steps below.
Deadline
For the 2020-2021 academic year, the deadline for consideration is April 15, 2021.
1. S
PECIAL CONDITION(S
)
I
ndicate the appropriate reason(s) and the date(s) of your family's change in circumstance by checking the box(es)
below. You will need to attach the required supporting documentation indicated below the applicable
circumstance(s).
Loss of employment or change in employment status since 20
18
• L
etter from employer on company letterhead that includes the last date of employmen
t.
• Unemployment benefits determination document.
• D
ocumentation of year-to-date incom
e.
L
oss of 2018 earnings due to disability or natural disaste
r
• D
ocumentation of disability determination
.
• Documentation of natural disaster.
• D
ocumentation of year-to-date income (copies of most recent pay stubs from all employers)
.
L
oss of 2018 untaxed income or benefi
t
(
Benefits received in 2018 were terminated or reduced in 2020
)
• Copy of notification of benefits reduction/termination, including the effective date.
• D
ocumentation of 2020 expected benefits
.
• D
ocumentation of Social Security benefits termination due to child reaching age 18
.
• Documentation of year-to-date income.
S
eparation or divorce since 2018 - Parties must live in separate residence
s
• Speak with the Financial Aid Office if the divorce or separation occurred before
y
ou completed the 2020-2021 FAFSA. Do not submit a Special Circumstances Appeal Form
.
• C
opy of divorce decree, or documentation of separation (Separate Maintenanc
e
A
greement or Attorney’s Letter and proof of separate residences. If legal documen
ts
d
o not exist, submit an explanation.
)
• To
tal 2020 net worth or liquid assets
.
Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
• Copy of 2018 Federal Tax Return Transcript(s) and all 2018 W-2 form(s). For information on how to obtain a
t
ax return transcript, https://www.irs.gov/individuals/get-transcript
.
Page 1 of 3
OFFICE USE ONLY: SPECCO
Death of parent/spouse since 2018
• C
opy of death certificate
.
Month/Day/Year
• Complete Section B only for surviving parent/student and attach income documentation
(
e.g. copy of last pay stub, proof of unemployment benefits) only for the survivi
ng
p
arent/student
.
Other
Provide
a detailed explanation and attach documentation for the circumstance(s) impacting the reduction in y
our
2020 family income as compared to your 2018 income. If additional space is needed, attach a separate sheet.
Page 2 of 3
OFFICE OF FINANCIAL AID
4525 Education Park Drive, Schnecksville, PA 18078
P 610.799.1133 | F 610.799.1798
E finaid@mymail.lccc.edu
2. STATEMENT OF ESTIMATED 2020 INCOME
Estimate your family income for the entire year (January 1, 2020 to December 31, 2020) by indicating the annual
amounts in each space below. If the question does not apply to you, indicate ‘0’ - do not leave any lines blank. This
form will be returned to you if it is incomplete and this will delay the processing of your financial aid.
If the student is Dependent, list parent(s) and/or student’s information.
If the student is Independent, list student’s and/or spouse’s (if applicable) information.
Dependent Student’s
Parent(s) Information
&/OR
Dependent or Independent
Student/Spouse’s Information
A. Expected 2020 Taxable Income
1. Wages, Salaries, Tips Father $ Student $
Mother $ Spouse $
2. Pension & Annuities $ $
3. Interest/Dividend Income $ $
4. Business or Farm Income $ $
5. Capital Gains $ $
6. Rents Which Will Be Received $ $
7. Alimony $ $
8. Unemployment Compensation $ $
9. Other Taxed Income, $ $
Explain:
B. Expected 2020 Untaxed Income & Benefits
1. Social Security $ $
2. Public Assistance $ $
3. Child Support $ $
4. Housing Allowance $ $
5. Retirement or Disability Benefits $ $
6. Worker's Compensation $ $
7. Payments to Tax-Deferred Pensions $ $
& Savings Plans
(Paid directly or withheld
from earnings
- include 401K & 403B plans)
8. Untaxed Portion of Pension $ $
9. Other Untaxed Income, $ $
Explain:
Total: $ Total: $
3. WET SIGNATURE(S) REQUIRED
By signing below, I/We certify that the above information is true and correct to the best of my/our knowledge:
Student Signature Date Student Daytime Phone Number
If Dependent, Parent Signature Date If Independent & Applicable, Spouse’s Signature Date
Ensure that Sections A, B and C are complete and that all of the required supporting documentation is attached
and return this form in person, via mail, fax, or email to finaid@mymail.lccc.edu at your earliest convenience.
OFFICE USE ONLY: SPECCO
Page 3 of 3
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2020-2021 Special Circumstances Appeal Form (Lehigh Carbon Community College)

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Completed 4 October 2020

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