Rev 2/28/14 PROFJD-15
MARITAL SEPARATION / DIVORCE after the FAFSA was
filed.
Date of divorce or separation: _____________________
Name of Custodial Parent:_______________________
• Documentation of separation, divorce or
verification of separate residences.
• Documentation of child support, family
support or maintenance support. Include
support that is received or anticipated.
ONE-TIME INCOME
One-time nonrecurring income (such as inheritance, retirement,
IRA distribution, etc) reported on the 2014-15 FAFSA that is no
longer available.
Parent 1 Parent 2 Spouse
• Provide documentation of one-time
income.
• Signed statement identifying the source of
income and how funds were spent or
invested.
DEATH OF PARENT / SPOUSE after the FAFSA was filed.
Parent 1 Parent 2 Spouse
Date of death:__________________________
• Legal documentation of death.
UNUSUAL MEDICAL AND DENTAL EXPENSES
Eligible expenses are limited to medical and dental expenses paid
and not reimbursed through insurance or employer-sponsored
cafeteria plans. Expenses must be at least 7.5% of the Adjusted
Gross Income (AGI) to meet the minimum threshold.
• Documentation of paid expenses not
covered by insurance or another party.
FILING STATUS
You disagree with the definition of an Independent Student, as
outlined by the U.S. Department of Education, as it applies to you.
Note: Living independently and not receiving monetary assistance
from your parent(s) does not classify you as an Independent
Student. Parents refuse to contribute to the student’s education
and/or unwilling to provide information on the FAFSA (or for
verification) singly or in combination, does not qualify.
• Signed statement describing how you are
independent of your parents and your
housing arrangement while in school and
during breaks.
• Three signed personal statements from
individuals not related to you (clergy,
governmental agency, school official, etc)
stating their personal knowledge of you
being independent.
OTHER UNUSUAL EXPENSES
• Provide documentation of expense.
STEP THREE: Certification Statement
I certify that the information on this form is complete and correct to the best of my knowledge. If additional documentation is
required, I will submit such documentation or my Special Circumstance Request will be denied. I also understand that if I
give false or misleading information, I may be fined, jailed, or both. I also understand that this information will be used in
accordance with Federal guidelines and may or may not result in adjustments to the student’s financial aid eligibility.
Student Signature:
Date:
Parent Signature:
Date:
Spouse Signature:
Date:
or Office use only
Ready for Review:
Review 1:
Approved Denied
Final decision:
Review 2:
Approved Denied
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