2021-2022
INCOME ADJUSTMENT PETITION
STUDENT INFORMATION
First name ________________________________ Middle Name __________________________________
Last Name ________________________________ Student ID Number ___________________________
BACKGROUND INFORMATION
The 2021-22 FAFSA/ WASFA calculates the Expected Family Contribution (EFC) based on your reported 2019
income and does not provide an opportunity to share information about changes to your income or circumstances.
We can review these circumstances with supporting documentation. If this petition is approve, the Financial Aid
Office will revise your FAFSA/ WASFA and adjust your EFC. This may result in a change to your financial aid offer.
Our ability to modify your offer will depend on availability of funds and the extent to which your circumstances
reduce your EFC.
A review of this petition does not guarantee an approval or adjustment to your financial aid offer.
The deadline to submit this petition is May 1
st
, 2022 or before the end of the last quarter attended. Allow a minimum
of 4-8 weeks for review and notification after initial file review is completed.
REQUIRED INFORMATION (for all circumstances)
1. Which calendar year’s income do you wish to be considered?
2020 2021
2. Briefly describe the change in circumstance (income loss/divorce/separation/death) and include all relevant
people and dates. You may attach an additional letter if more space is needed.
Continued onto page 2
Submit this form in person or mail, electronically, or by fax:
Financial Aid Office, Everett Community College, 2000 Tower S
treet, Everett, WA, 98201
fin_aid@everettcc.edu • Fax (425) 388-9185
Everett
Community College does not discriminate based on, but not limited to, race, color, national origin, citizenship, ethnicity, language,
culture, age, sex, gender identity or expression, sexual orientation, pregnancy or parental status, marital status, actual or perceived disability,
use of service animal, economic status, military or veteran status, spirituality or religion, or genetic information.
ADDITIONAL REQUIRED DOCUMENTATION (for your specific circumstance)
Please select the circumstance below that best applies to you and/or your family. You are required to
supply all of the documentation listed in the section you choose.
Dependent students are required to provide information for their parent(s).
Independent students are required to provide information for themselves (and their spouse, if applicable).
Reduction or loss of income
The 2019 income on your FAFSA/ WASFA does not reflect your current income due to the loss of a job, a
reduction in hours, or the income including a one-time benefit. You (and your spouse or parent(s)) must
provide:
1) Relationship to student: ________________________
Date change occurred: ________________________
Date of new job, if applicable: ____________________
2) If change occurred in 2020: Student/spouse or parent(s) 2020 tax forms and W-2
OR
If change occurred in 2021: Most recent paystub(s) with Year-to-Date (YTD) listed for all jobs
3) If applicable, Year-to-Date (YTD) statement of unemployment benefits or other benefits
Divorce, separation, or change in marital status after application submitted
At the time you completed the FAFSA/ WASFA, you either 1) included your spouse’s income but since
then have divorced or separated, or 2) included both parent’s income but they have since divorced or
separated. You or your parent (if applicable) must provide:
1) Relations
hip to student: _________________________
Date marital status change occurred: _______________
If ap
plicable, Child support received/ paid per month. Date began: __________ Amount: $ _________
Alimony received/ paid per month. Date began: __________ Amount: $ _________
Mark one: Recei
ved ____ Paid: _____
2) Most recent paystub(s) with Year-to-Date (YTD) listed for all jobs for student and spouse or parent
Death of a spouse or parent
At the time you completed the FAFSA/ WASFA, you included income from a spouse or parent that has
since passed away. You or your parent (if applicable) must provide:
1) A death c
ertificate or obituary
2) You or your living parent’s most recent paystub(s) from all jobs, with 2021 Year-to-Date (YTD)
earnings listed
CERTIFICATION
By signing this worksheet, I affirm that I have read, understood, and agreed to this form in its entirety and that the
information supplied is true and complete.
Student Signature _______________________________________
Parent Signature (if applicable) ______________________________
Date _______________________
Date ______________________