Fillable Special Circumstance Form 18 19 (University of Dayton)

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Special Circumstance Form 18 19 (University of Dayton)

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Special Circumstance Appeal Form
2018-19 Academic Year
The University of Dayton strives to offer our families the best financial aid packages possible within the limitations of federal, state and
university funding levels. We understand that the FAFSA does not always capture the current financial snapshot of your household and that
certain circumstances may present your family with unique financial challenges. By completing this form, we will be able to determine if these
factors have any effect on your 2018-19 expected family contribution (EFC), which in turn affects your need.
Instructions
Please complete this form in its entirety. Please provide documentation which supports your reason for your appeal and include the student’s
name and student ID number on all documents to insure proper identification. In addition, we must have the results of your 2018-19 FAFSA
(Free Application for Federal Student Aid) on file in order to review this form. This can be filed online at http://www.fafsa.gov. If your
FAFSA is selected for federal verification, that process must be complete before your special circumstance appeal form can be reviewed.
Your appeal will be evaluated by the financial aid staff within a timely manner based on the volume received. Please allow up to two (2)
weeks for review. For your convenience, you can email, mail or fax the documentation to us. If you need assistance in completing this form,
please use the following contact information:
First-year students:
Office of Admission and Financial Aid
1-800-837-7433 or 1-937-229-4411
FAX: 937-229-4338
admission@udayton.edu
Non first-year students:
Office of Financial Aid
1-800-827-5029 or 1-937-229-4311
FAX: 937-229-4338
finaid@udayton.edu
Student Information
Last Name: First Name: MI: Student ID#:
Address:
City: State: Zip: Date of Birth:
Phone Number: Email Address:
Your grade level for the 2018-19 academic year: First year Sophomore Junior Senior
Reason(s) For Appeal
Loss of income/benefits (due to unemployment, loss of overtime, loss of non-recurring income/benefits, death of wage earner, divorce,
separation, loss of child support received, etc.)
Loss of income/benefits took effect in the 2017 tax year or Loss of income/benefits took/will take effect in the 2018 tax year
(complete SECTION A and C ) (complete SECTION B and C)
Please attach letter from employer, unemployment statement, most recent pay stub(s), etc.
Unreimbursed medical/dental expenses (out-of-pocket expenses after insurance payments, etc.)
Amount paid during the 2017 tax year $ _____ _ __ .00 or Amount paid/ during the 2018 tax year $ __________ _ .00
(complete SECTION A and C) (complete SECTION B and C)
Please attach copies of year-to-date payment statement(s), 1040 Schedule A (if applicable), etc.
Other unusual/one-time occurrence expenses/payments (unreimbursed expenses for elder care of loved one, adult child not living in
household, funeral expenses, etc. or one-time cash/income payments received inflating AGI such as retirement fund rollover):
Amount paid during the 2017 tax year $ ______ __ .00
or Amount paid/anticipated during the 2018 tax year $ ___ _ __ .00
(complete SECTION A and C) (complete SECTION B and C)
E
xpense: ______________________________________ Expense: ______________________________________
Expense: ______________________________________ Expense: ______________________________________
Please attach copies of supporting documentation
Continued on next page
UD ID #:
N
ame:
Complete either section A or B, based on your responses on page one. Refers to individuals whose information was provided on your
2018-19 FAFSA.
SECTION A:
Actual 2017 Income
Please provide all ACTUAL income sources from January 1 - December 31, 2017.
Also, provide copies of most recent pay stub for all wage earners listed below.
Student/Spouse Information Parent Information (dependent students)
Actual 2017 Taxable Income Actual 2017 Taxable Income
Student’s earned income $ _______________.00
S
pouse’s earned income (if applicable) $ _______________.00
O
ther taxable income* $ _______________.00
Total taxable student income $ _______________.00
Father/stepfather’s earned income $ _________________.00
M
other/stepmother’s earned income $ _________________.00
O
ther taxable income* $ _________________.00
Total taxable parent income $ ________________.00
* including, but not limited to, unemployment compensation, alimony received, distributions from Ira/pension/annuity, business income, gains, etc.)
Actual 2017 Non-taxable Income
Actual 2017 Non-taxable Income
Child support received $ _______________.00
O
ther non-taxable income** $ _______________.00
Total non-taxable student income $ _______________.00
Child support received $ ________________.00
O
ther non-taxable income** $ ________________.00
Total non-taxable parent income $ ________________.00
** including, but not limited to, untaxed portions of IRA/pension/annuity disbursements, IRA deductions and payments, tax exempt interest income, etc.)
SECTON B:
Estimated 2018 Income
Please provide all ANTICIPATED income sources your family expects to have from January 1 - December 31, 2018.
Also, provide copies of most recent pay stub for all wage earners listed below.
Student/Spouse Information Parent Information (dependent students)
Estimated 2018 Taxable Income
Estimated 2018 Taxable Income
Student’s earned income $ _______________.00
S
pouse’s earned income (if applicable) $ _______________.00
O
ther taxable income* $ _______________.00
Total taxable student income $ _______________.00
Father/stepfather’s earned income $ _________________.00
M
other/stepmother’s earned income $ _________________.00
O
ther taxable income* $ _________________.00
Total taxable parent income $ ________________.00
* including, but not limited to, unemployment compensation, alimony received, distributions from Ira/pension/annuity, business income, gains, etc.)
Estimated 2018 Non-taxable Income Estimated 2018 Non-taxable Income
Child support received $ _______________.00
O
ther non-taxable income** $ _______________.00
Total non-taxable student income $ _______________.00
Child support received $ ________________.00
O
ther non-taxable income** $ ________________.00
Total non-taxable parent income $ ________________.00
** including, but not limited to, untaxed portions of IRA/pension/annuity disbursements, IRA deductions and payments, tax exempt interest income, etc.)
0
0
0
0
UD ID #:
Name:
SECTION C: Required for all appeal reasons.
Briefly explain your reason for requesting additional financial aid and be sure to provide supporting documentation.
Signatures Required:
I (We) certify that I (we) have read all instructions and attached all required documentation to allow for a thorough review of this
appeal. I (we) also realize that completing this form does not guarantee an increase to the current financial aid award.
Student’s signature
Parent’s signature
Date
Date
Office of Financial Aid
300 College Park
Dayton, Ohio 45469 -1605
FAX: 937-229-4338
www.finaid.udayton.edu
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Special Circumstance Form 18 19 (University of Dayton)

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Completed 25 July 2020

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