1
Financial Aid Office, 2755 E. Napier Avenue
Benton Harbor, MI 49022
Phone: 269-927-8112/ Fax: 269-927-8183
Email: finaid@lakemichigancollege.edu
SPECIAL CIRCUMSTANCES REQUEST FORM - DEPENDENT STUDENT | 2020-2021
Occasionally, unusual circumstances exist that may warrant reconsideration of financial aid eligibility. These special
circumstances may be changes that have occurred in your family circumstances since you filed the Free Application
for Federal Student Aid (FAFSA) or unusual family circumstances not accounted for on the FAFSA. We have listed
the circumstances that most commonly qualify a student to file a Special Circumstances request. Select as many
circumstances that fit your current situation.
To Qualify for a Special Circumstances Review, You Must:
Write a letter explaining your particular situation
Complete all pages of this form
Provide all requested documentation
Choose one or more of the situations outlined on the following pages
If your circumstance(s) does NOT fit into one of the options, you may still file the Special Circumstances Form. Please attach a
letter explaining your situation as well as any supporting documentation.
Please note: Filing this appeal does not guarantee additional financial aid. Some appeals may only result in the student
receiving the maximum in subsidized loan eligibility and/or Pell grant eligibility. Please allow 3-4 weeks for processing.
Student Name: Student ID Number:
Phone Number: LMC E-mail:
CERTIFICATION AND SIGNATURE: By signing this form, you are certifying that all of the information reported on the form is
complete and accurate. All attachments and supporting documents are true to the best of our knowledge. I further understand
that
purposely giving false or
misleading information may result in fines, jail terms, or both.
Student Signature: Date:
Please return your completed form and required documentation to the Office of Financial Aid by fax, U.S. mail, email or
in person. Be sure to include your name and LMC ID on all pages. Missing information may delay processing.
Parent Signature: Date:
2
Loss of Income
Reduction or loss of income from work must be for at least ten (10) weeks or sufficient documentation of change and new
employment.
Parent 1 (father/mother/stepparent)
Date of layoff/termination:
Parent 2 (father/mother/stepparent)
Date of layoff/termination:
Student
Date of layoff/termination:
Has the parent started another job? No
Yes If yes, give start date:
Yes If yes, give start date:
Has the student started another job? No
Required Documentation:
A letter from employer verifying loss of employment including effective date
A copy of the last pay statement showing gross earnings year-to-date income for all jobs worked for parent(s).
If more than one employer per parent, please include start/end date in written statement.
Documentation of unemployment benefits from state agency
Documentation of severance pay received, or IRA’s, stocks, bonds, pensions, etc. (converted to cash).
Loss of Child Support
Name of Child: Amount received in 2020: Date support ended:
Name of Child: Amount received in 2020: Date support ended:
Required Documentation:
A copy of legal separation/divorce decree that specifies amount of child support
Statement from the Friend of the Court documenting amount of child support
Receipt of One-Time Income
Consideration for and one-time income may only be reviewed once during a student’s enrollment at Lake Michigan College.
Required Documentation:
A signed copy of your 2018 U.S. Federal Tax Return and/or 1099 Form
Written statement explaining the reason for early withdrawal
Separation or Divorce of Parents since 2018
Please note that you must be residing in separate households and provide documentation.
Date of separation/divorce:
Which parent will the stu
dent live with or which parent will provide the financial support?
Moth
er/Stepmother
Father/Stepfather
Required Documentation:
A copy of supporting parent’s most recent pay statement; and
A copy of the divorce decree/legal separation papers; and
Documentation of spousal support and/or child support.
Death of a Parent since 2018
Mother/Stepmother
Father/Stepfather
Date of death:
Required Documentation:
A copy of the death certificate; and
Surviving parent’s 2020 income information.
Other Circumstances not addressed in the above categories
Required Documentation:
Submit a statement that explains changes in your financial and/or family situation; and
Supporting documentation.
3
Household Size Statement
Please list the names and ages of all the members of your household* during the 2020-2021 academic year. Also,
please indicate which family members (excluding parents) will be enrolled in college at least half-time during 2020-
2021 and which institution they are planning to attend.
The term “Household” is defined as follows:
The household includes yourself, your parents and your parents’ other children if (a) your parents provide more
than half of their support or (b) the children would be required to provide parental information when applying for
Federal Student Aid. Include other people only if they now live with your parents, and your parents provide more
than half of their support and will continue to provide more than half of their support from July 1, 2020 through
June 30, 2021.
Name Age Relationship Name of College
Self Lake Michigan College
Estimated Household Income
All Sources of Income for 2020 Year to Date: 1/1/2020- Estimated: Today-12/31/20
Today
Parent 1
Name
Total Wages, Salaries, Tips $ $
Parent 2
Name
Total Wages, Salaries, Tips $ $
Student Total Wages, Salaries, Tips $ $ ________________
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