Student Name _____________________________________________________ 2019-20 Request for
Student ID or Star ID _______________________________________ Professional Judgment
Address __________________________________________________ COVID19 Loss of
Income
Person Completing Form ___________________________________________
Phone _______- __________ - _____________ Email Address ___________________________________________________
I am requesting the Financial Aid Office to consider a change of income that more accurately reflects my current
financial situation due to a financial hardship caused by COVID19.
You are required to submit the following documents with this completed form:
o A signed copy of your federal 1040 tax return for 2017
o The estimated income worksheet on the back of this page
o A copy of your most recent pay stub
Please use this space to explain your job loss. Include details such as where you worked, what date were
you laid off, if/when you expect to be reemployed and any other important details you think we should be
aware of:
___________________________________________________________________
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___________________________________________________________________
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___________________________________________________________________
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___________________________________________________________________
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Financial Aid Office
3300 Century Avenue North
White Bear Lake, MN 55110
Phone: 651-779-3305
Fax: 651-779-5816
E-mail: finaid@century.edu
A MEMBER OFTHE MINNESOTA STATE COLLEGES & UNIVERSITY SYSTEM
AN AFFIRMATIVE ACTION EQUAL OPPORTUNITY EMPLOYER & EDUCATOR
2020 Estimated Income Projections
Wages, salary, tips and all other taxable income (do not include financial aid wages through work study
employment).
Actual Amount: Estimated Amount:
1/1/2020 to today’s date Today’s date to 12/31/2020 2020 total taxable income
Student $ _____________ + Student $ _____________ = $_________________________
Spouse $ _____________ + Spouse $ ______________ = $ _________________________
Parent(s) $ ___________ + Parent(s) $ _____________ = $ _________________________
Unemployment earnings should not be included in the above income estimations. Please provide proof of any
unemployment income by submitting your unemployment approval documentation along with this form.
Untaxed income (child support, payments to tax deferred pensions and savings, untaxed portions of IRA
distributions, workers compensation, other untaxed income)
Please specify type of untaxed income _____________________________________________________________
Actual Amount: Estimated Amount:
1/1/2020 to today’s date Today’s date to 12/31/2020 2020 total untaxed income
Student $ ____________ + Student $ _______________ = $ __________________________
Spouse $ _____________ + Spouse $ ________________ = $ __________________________
Parent(s) $ ___________ + Parent(s) $_______________ = $ __________________________
Household Size Information
List all members of your household in the boxes below. If you are married, include your spouse and children (if
any). If you are a dependent student, list your parents and any siblings/dependents that your parents will
support between July 1, 2019 and June 30, 2020. List the name of the college each attends, if applicable.
Full Name
Age
Relationship to Student
College Currently
Attending
Enrolled in 6 or
more credits?
(Yes or No)
Self
Century College
The information and projections are true to the best of my knowledge. I understand that no adjustment will be made
to the financial aid application without the appropriate supporting documentation and that the Financial Aid
Administrator may ask for additional documentation that may deviate from the items listed under each category.
Student Signature: ___________________________________________________________ Date: ____________________
Parent Signature (if dependent student): _______________________________________ Date: ____________________
To be completed by Financial Aid Office Staff
_____ Approved ______ Denied ______ Updated: See comments in ISRS.
________________________________________________________________________ ________________________
Financial Aid Staff Signature Date
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