Fillable Medical-expenses-18 Medical Expenses Adjustment Request

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Medical-expenses-18 Medical Expenses Adjustment Request

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University of Central Missouri
Office of Student Financial Services
P.O. Box 800
Warrensburg, MO 64093-5178
Phone 660-543-8266 FAX 660-543-8080
On-line: www.ucmo.edu/contactsfs
Webpage: www.ucmo.edu
/sfs
Medical Expenses
Adjustment
Request
2018/2019
UCM use only
Medical_Expenses_18.pdf NOV 3,2017
MEDCL
_______
_________________________________________________
700 ___________________________________
Student's Name (please print) UCM ID Number
I am requesting that the medical expenses ___ I or ___ my parent(s) were required to p
ay out-of-pocket
during the 2016 calendar year be considered in the calculation of my eligibility for federal financial aid.
Following is an explanation of these medical expenses and when they were incurred and/or paid:
A total of $______________ was paid out-of-pocket during the 12-month 2016 calendar year for the
above medical expenses. I (we) certify that none of this amount was (or will be) paid (or reimbursed)
by medical/health insurance or by any other agency or individual. Documentation must be provided for
all expenses.
Please explain if any of the above expenses are still unpaid or outstanding:
A photocopy of Schedule A of the 2016 federal tax return must be included with this request. If a
Schedule A was not filed, invoices and/or photocopies of canceled checks must be included.
FA
ILURE TO PROVIDE ALL INFORMATION AND REQUIRED DOCUMENTS CAN
DELAY THE RECALCULATION OF YOUR FINANCIAL AID ELIGIBILITY.
I (w
e) certify that the medical expenses information provided on this form is true and accurate to the best
of my (our) knowledge. I (we) also understand that any adjustments made by the UCM Office of Student
Financial Services will be based on federal guidelines, and a change to my federal financial aid eligibility
may or may not be permitted.
Student’s Signature Date
Parent’s Signature Date
Complete and submit this form (and the required documents) to the UCM Office of Student Financial
Services in person (1100 Ward Edwards Bldg.) or by mail (Student Financial Services, P.O. Box 800,
Warrensburg MO 64093-5178), or by fax (660-543-8080).
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Medical-expenses-18 Medical Expenses Adjustment Request

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Completed 19 November 2019

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