Fillable form to the Financial Aid Office if you, (Minot State University)

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form to the Financial Aid Office if you, (Minot State University)

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2020-21 Special Circumstance Form
If your family situation has changed significantly from the information you were required to provide on the 2020-21 FAFSA, your 2018 income may
not be an accurate indicator of your family’s ability to contribute to your educational costs. In some cases, Minot State Financial Aid may be able to
make an adjustment based on your 2019 actual income or projected 2020 income rather than 2018 income information. Complete and return this
form to the Financial Aid Office if you, your spouse, or a parent has incurred an unusual expense or unusual change in income.
A.
Student Information
_ __
Last Name First Name MI Date of Birth Student ID
_
Address (include apartment number) Email Address
_
City State Zip Phone Number
Who incurred the unusual expense or circumstance? Student Spouse
Parent 1
Parent 2
Indicate amount of additional funding you are requesting: $
B. Documentation
Supporting documentation that verifies your unusual expense or circumstance must be attached. See page 2 for
required documentation. Forms submitted with incomplete documentation will not be processed.
Please check all circumstances you would like to have considered from the list below.
Childcare expense Housing Costs
Computer purchase Commuting Expense
Death of parent Separation or Divorce
Loss of benefits Liquidation or Foreclosure of Assets
Roth IRA rollover Loss of Income/Employment
Parent enrolled in college Medical Expenses
Elementary/Secondary School Tuition Other
Projected income from January 1, 2020
to December 31, 2021
Student Spouse
Parent 1 Income
List Parent
Name:
Parent 2 Income
List Parent Name:
2020 Gross Earnings from Work
$
$
$
$
2020 Unemployment Benefits
$
$
$
$
2020 Child Support Received
$
$
$
$
2020 Worker’s Compensation
$
$
$
$
2020 Other Income:
$
$
$
$
D.
Sign and Date This Worksheet
All the information provided by the undersigned is true and complete to the best of my/our knowledge. I/we further understand that
purposely giving false or misleading information to obtain student financial aid may subject me/us to fines and other penalties.
Student Signature Date Parent Signature Date
-OVER-
C. Loss of Income/Employment
(
Complete this section if your Special Circumstances includes a loss of income AND your 2020
income
will be less than your 2019 income.)
E.
Required Documentation
Special Circumstance Documentation
Child Care Expense
Letter listing:
a.
Name and age of dependent(s)
b.
Hourly rate paid
c.
Total monthly cost
d.
Name & address of provider
Housing Costs
1.
Copy of rental agreement or mortgage payment
2.
Copy of most recent monthly utility bills
Computer Purchase
Copy of purchase order or receipt for purchase of a computer (purchased
between August 20
20 and May 2021)
Commuting Expense
Letter listing:
a.
Number of miles traveled each day and how many days you travel
b.
Where you are traveling from
Death of a Parent
1.
Letter listing:
a.
Relationship of deceased to the student
2.
Copy of obituary
3.
Copy of 2019 federal tax return and W2s
Separation or Divorce
1.
Letter listing:
a.
Revised household members
2.
Copy of divorce decree or proof of separation
3.
Copy of 2019 federal tax return and W2s
Loss of Benefits
1.
Letter listing:
a.
Whose benefit(s) was terminated
b.
Amount of benefit(s) received for last two years
c.
Reason for termination
2.
Copy of document from provider stating termination
3.
Copy of 2019 Federal tax return and W2s
Liquidation or Foreclosure
1.
Letter listing:
a.
Type of asset liquidated
b.
Gross sales proceeds
c.
List of where proceeds were applied
2.
Copy of foreclosure notice
3.
Copy of 2019 federal tax return and W2s
Roth IRA Rollover
1.
Copy of documents from investment agency verifying the rollover of pension or IRA
to a Roth
IRA
2.
Copy of 2018 federal tax return and W2s
Loss of Employment
1.
Letter listing
a.
Who lost employment and when
b.
Reason for loss of employment
c.
Income earned and untaxed income (Worker’s Compensation,
unemployment benefits, disability benefits, etc.) to date of
termination (per family member))
d.
Projected income and untaxed income to the end of 2020
2.
Copy of last pay stub from all employers for 2020
3.
Copy of 2018 federal tax return and W2s
4.
Copy of 2019 federal tax return and W2s
Parent Enrolled in College
Letter listing:
a.
Which parent is enrolled
b.
Number of enrolled credits
c.
Enrollment verification form from the college showing that parent is
enrolled ½ time or greater in a degree granting program
Medical Expenses
1.
Letter listing:
a.
Who incurred the expense(s)?
2.
List of medical expenses incurred (only paid bills will be considered)
3.
Copy of Explanation of Benefits from insurance provider
4.
Copy of medical bills
Elementary/Secondary
School
Tuition
Letter listing:
a.
Person for whom tuition is being paid
b.
Copy of tuition contract
Forms can be submitted in ONE of the following ways:
Mailing to: Minot State University, Financial Aid Office, 500 University Ave W, Minot, ND 58707
Drop Off on Campus: Minot State Financial Aid Office, 2nd floor, Administration Building
Submitting online via our secure filedrop by visiting:
MinotStateU.edu/finaid/verification.shtml
Phone: 800-777-0750 or 701-858-3375 • Fax: 701-858-4310 • For additional questions, email: Laurie.Weber@minotstateu.edu
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Completed 23 August 2020

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