Fillable 2020-2021 Special Circumstances Form (Washington State Community College)

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2020-2021 Special Circumstances Form (Washington State Community College)

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Office of Financial Aid
710 Colegate Drive, Marietta, OH 45750
Phone: 740.568.1908 Fax: 740.376.0257
E-mail: finaid@wscc.edu
2020-2021 Special Circumstances Form
Student Name: ___________________________________ WSCC ID: _______________ DOB: _____/_____/__________
STEP 1: EXPLANATION OF SPECIAL CIRCUMSTANCES:
Please attach a separate signed statement detailing the specifics of your circumstances and providing any important
information that will help us better understand your particular situation.
STEP 2: SPECIAL CIRCUMSTANCES FOR CONSIDERATION:
Please check which Special Circumstance applies to you. Any documentation listed as required but not submitted will
cause a delay in our ability to review your request until every required document has been received.
The required documentation listed below is for a change that occurred in 2019. If you are requesting a change that has
occurred in 2020, please contact the Financial Aid Office to see what additional documentation is required.
SPECIAL
CIRCUMSTANCE
FOR A
DEPENDENT
STUDENT
FOR AN
INDEPENDENT
STUDENT
REQUIRED
DOCUMENTATION
Loss of Employment*
Your parent(s’) or
your income earned
in 2019 will be less
than that earned in
2018.
Your (and/or your
spouse’s) income
earned in 2019
will be less than
that earned in 2018.
Complete signed copies of:
1. 2019 Federal Tax Transcript
2. W-2 Wage statements for parent(s)/student
3. Last pay stub showing year-to-date earnings
4. Termination notice from employer
5. Benefit notice from employment office
Loss of Taxable/Untaxed Income
Child Support
Social Security
Worker’s Compensation
Alimony
Your parent(s) or
you received
benefits in 2018
which have ceased
or been reduced in
2019.
You (and/or your
spouse) received
benefits in 2018
which have ceased or
been reduced in 2019.
Complete signed copies of:
1. 2019 Federal Tax Transcript
2. W-2 Wage statements for parent(s)/student
3. Documentation from agency stating total
amount received in 2018 & termination date
4. Documentation of 2018 updated amount
Separation or Divorce
Your parents have
separated or
divorced AFTER
filing the FAFSA.
You and your
spouse have
separated or
divorced AFTER
filing the FAFSA.
Complete signed copies of:
1. 2019 Federal Tax Transcript
2. W-2 Wage statements for parent(s)/student
3. Divorce decree or separation agreement or
proof of separate addresses
Death of a Parent or Spouse
A parent has died
AFTER filing the
FAFSA.
Your spouse has
died AFTER filing
the FAFSA.
Complete signed copies of:
1. 2019 Federal Tax Transcript
2. W-2 Wage statements for parent(s)/student
3. Death certificate
Medical/Dental Expense*
Use this circumstance if you have
excessive medical expenses not
covered by insurance:
*EXPENSES PAID IN CALENDAR YEAR 2018
Your parent(s’) or
your medical
expenses in 2018
exceeded 11% of
your AGI.
Your (and your
spouse’s) medical
expenses in 2018
exceeded 11% of
your AGI.
Complete signed copies of:
1. 2019 Federal Tax Transcript
2. W-2 Wage statements for parent(s)/student
3. Payment of medical bills
4. Letter from insurance company showing
medical expenses not covered
Continue to next page…
STEP 3: PROJECTED INCOME AND BENEFITS FROM JANUARY 1, 2019 TO DECEMBER 31, 2019
SOURCE OF INCOME:
FATHER/
STEPFATHER
MOTHER/
STEPMOTHER
STUDENT
Wages, Tips, Salary
$
$
$
Interest and/or Dividend Income
$
$
$
Business/Farm Income
$
$
$
Unemployment Compensation
$
$
$
Worker’s Compensation
$
$
$
Pensions and/or Annuities
$
$
$
Severance Pay
$
$
$
Retirement Benefits
$
$
$
Disability Benefits
$
$
$
Social Security/SSI Benefits
$
$
$
Child Support
$
$
$
Alimony
$
$
$
Welfare Benefits
$
$
$
Other:
$
$
$
TOTAL OF ALL INCOME:
$
$
$
COMPLETE ONLY IF YOUR SPECIAL CIRCUMSTANCE IS FOR MEDICAL/DENTAL EXPENSES PAID IN 2018.
Medical/Dental Expenses in 2018
$
$
$
STEP 4: STATEMENT OF CERTIFICATION
All of the information on this form is true and complete to the best of my knowledge. If requested, I agree to provide
further documentation to confirm the information provided. I understand that all special circumstances are reviewed on
a case-by-case basis and this written request does not guarantee approval and/or may not ultimately result in actual
change of the financial aid already offered. (All persons providing information must sign below.)
_________________________________________________ ______________________________
Student’s signature Date
_______________________________________________ ______________________________
Student’s Spouse’s signature (if applicable) Date
_______________________________________________ ______________________________
Parent’s signature (if student is dependent) Date
HAVE YOU PROVIDED ALL OF THE FOLLOWING?
Written Detailed Statement of circumstance
Tax transcripts, schedules, and W-2 Wage Statements
All Required Documentation as indicated
Appropriate Signatures on ALL forms
Student’s Name and DOB on ALL forms
OFFICE USE ONLY
Approved PELL Special Condition
Adjusted Gross Income $________________
Denied PELL Special Condition
Estimated 2019 Tax $___________________
Student Not Eligible for Special Condition
__________________________________
Reviewed & Approved by Date
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2020-2021 Special Circumstances Form (Washington State Community College)

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Completed 26 July 2020

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