Special Circumstances Form
Dependent Student
Office of Financial Aid 100 East 8
Street PO Box 9000 ▪ Holland, MI 49422-9000
P: 616-395-7765 ▪ F: 616-395-7160 ▪ ▪
If your parent(s) 2020 projected income is expected to be significantly less than that of 2018 or 2019, your parent(s)
should provide the requested information. The parent must be involuntarily unemployed for at least 8 weeks.
Student Name:
Hope College ID Number:
1. Attach a detailed letter explaining the circumstances affecting your family’s income for the period of
January 1, 2020 to December 31, 2020. Unemployment must not be voluntary.
2. Provide a signed copy of parents 2018 and 2019 federal 1040 tax return/W-2 forms.
3. Provide documentation of parental income estimates (copies of pay stubs, unemployment stubs,
severance or separation pay, verification of retirement, pensions, Social Security benefits, etc). For loss of
employment, also attach a letter from the past employer on company letterhead confirming loss of
employment and the effective date.
Father's expected gross income from work $____________
Mother's expected gross income from work $____________
Net income from business, farm, rentals, royalties, partnerships, estates, trusts, etc. $____________
Unemployment benefits for ____ father or ____ mother $____________
Severance or separation pay not included in income from work $____________
Taxable Social Security Benefits $____________
Taxable Pension or Retirement Benefits $____________
Untaxed Social Security Benefits for all family members including SSI disability benefits $____________
Welfare Benefits including TANF but not food stamps or housing assistance $____________
Child Support $____________
Housing, food, & living allowances paid to members of the military, clergy, etc.
(including cash payments and cash value of benefits). $____________
Veterans’ noneducation benefits such as Disability, Death Pension, Dependency &
Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances $____________
rker’s compensation and disability payments $____________
Any other untaxed income and benefits*: Source(s): _______________________ $____________
*EXCLUDE Workforce Investment Act educational benefits, benefits from flexible spending arrangements
(e.g. cafeteria plans), and combat pay if you are not a tax filer.
5. Child support to be PAID OUT in 2020 because of divorce or separation $____________
NOTE: Be sure to notify us if your circumstances improve. If through a later review of your
2020 documentation we find that you significantly underestimated your 2020 income, the
student’s aid eligibility will be adjusted accordingly the following year.
Parent Signature: ______________________________ Date Signed: