Change in Financial Situation
2020-2021
Last Name First Name Middle Initial
___________________________________________________ ( )
Current Address Phone Number (Daytime)
City State Zip
( ) __________________
Social Security Number
Student ID #
E-mail Address
To
request
2019
income
to
be
used
to
determine
your
financial
aid
eligibility,
complete
Section
A,
B,
and
C,
attach
documentation,
sign
and
return
to
the
Financial
Aid
office.
Only
circumstances
that
are
beyond
a
student/spouse/parent(s) control
will be
taken into consideration.
If you/your spouse’s/and/or your parent(s) income will be less in
2019
than 2018
for any reasons listed below,
check the appropriate reason in
Section A, complete Section B,
and explain your situation in Section
C.
SECTION A:
Unemployment
or change in employment (e.g. termination/layoff letter from employer, unemployment
statement, dislocated worker form).
Death
of student’s parent or spouse (e.g. copy of death certificate, obituary, eulogy).
Disability
of student, parent or spouse (e.g. medical document, accident report).
Other
(submit appropriate documentation).
Loss
of one-time income (e.g. military separation, pension or retirement, inheritance, court settlement)
Identify the source
and
amount
of income
and how the funds are spent or invested in Section C.
Provide your/your spouse’s/and/or parent(s) expected income and resources for the period January
2019 through
December
2019.
Documentation (W-2s, 1099s, tax returns, etc.) must be attached.
SECTION B: You (SSpouse tep) Father (Step) Mother
Wages, salaries, tips (income from work) __________ __________ __________ __________
Unemployment compensation __________ __________ __________ __________
Other taxable income Specify __________ __________ __________ __________ __________
AFDC/ADC/TANF __________ __________ __________ __________
Social Security benefits __________ __________ __________ __________
Child Support (Received) __________ __________ __________ __________
Child Support (Paid) To whom __________ __________ __________ __________ __________
Alimony __________ __________ __________ __________
Other untaxed income Specify __________ __________ __________ __________ __________
There must be a number on all lines, even if they are 0’s
Financial Aid Office
7390 S. 6
th
Street
Klamath Falls, OR 97603
(541) 882-3521
www.klamathcc.edu
2020-2021
Change in Financial Situation
Klamath Community College is an
equal
opportunity
educator and
employer
SECTION C: Explain in detail your change in circumstances
Date of Occurrence:
I understand that my request will not be processed if it is incomplete or if documentation is not attached. I
have attached the required documentation from page one for consideration of this request.
I certify the information provided on this form is true and correct to the best of my knowledge. I acknowledge
that incorrect information may affect future financial aid funding.
Student: ___________________________________________________ Date:
Signature
Spouse: ___________________________________________________ Date:
Signature
(Step) Parent: _____________________________________________ Date:
Signature
(Step) Parent: ______________________________________________ Date:
Signature
OFFICE USE ONLY
Approved per Professional Judgment Denied Pending
FA Approval Date
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