If your family has high medical/dental/vision expenses that exceed 5% of the parent(s)’ Adjusted Gross Income (AGI), please upload this
form (with documentation) to IDOC so we may review these costs when determining financial aid eligibility. Medical costs listed below can
only be the result of out-of-pocket expenses that the family paid in the 2019 calendar year. Expenses covered under any health insurance
program or other entity (including medical spending accounts) cannot be considered.
Please provide documentation for payments made in the 2019 calendar year, such as receipts, bank or credit card
statements, account summaries, etc. Documentation must show the amount paid, date of payment, and description of services for
the medical expense. Please highlight all payments on corresponding documentation. If you itemized your medical expenses on
Schedule A of your 2019 federal tax return, you may submit your 2019 Schedule A in lieu of other documentation. If submitting your 2019
Schedule A, please use this sheet to list your itemized medical expenses by the type of expense (doctor’s visit, prescriptions, dental, vision,
etc.).
All items listed must have supporting documentation. Items that are listed without documentation will not be considered. Items submitted are
subject to approval by the Financial Aid Office. Additional information may be requested. If you need additional space, please make a copy
of this form and number each page that you submit.
Please list the type of expense (doctor’s visit, prescriptions, dental, vision, etc.), the doctor/company (e.g. CVS Pharmacy, Dr. Green DDS),
the total paid to that doctor/company in 2019, and the type of documentation you are providing to substantiate that cost (e.g. receipts, bank
statements, Schedule A).
Type of Expense:___________________________________________ Doctor/Company:_______________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided: _______________________________________
Type of Expense: _____________________________________________ Doctor/Company _______________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided: ________________________________________
Type of Expense: __________________________________________ Doctor/Company: _____________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided: _______________________________________
Type of Expense: _____________________________________________ Doctor/Company:_______________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided: ________________________________________
Type of Expense: __________________________________________ Doctor/Company:_______________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided:________________________________________
Type of Expense: _____________________________________________ Doctor/Company: ______________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided: _______________________________________
Type of Expense: _____________________________________________ Doctor/Company: ______________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided: _______________________________________
Type of Expense: _____________________________________________ Doctor/Company: ______________________________________________
Amount Paid in 2019 $_________________________________________ Documentation Provided: _______________________________________
Page # _____
I certify that all information reported on this form and any attachments and subsequent information provided to the Occidental College
Financial Aid Office is true, complete, and accurate to the best of my knowledge. I understand that false statements or misrepresentations will
be cause for denial, reduction, withdrawal, and/or repayment of financial aid.
Parent Signature (no electronic signatures) Print Name Date
MEDICAL/DENTAL/VISION PAYMENTS (2019 calendar year)
STUDENT’S NAME:
OXY ID:
(NEW STUDENTS LEAVE BLANK)
MEDICAL/DENTAL/VISION
EXPENSE SHEET
2020-2021
Occidental College
Financial Aid Office
1600 Campus Road F-35
Los Angeles, CA 90041
Phone: 323-259-2548
Fax: 323-341-4961
finaid@oxy.edu
www.oxy.edu/financial-aid
