Eastman School of Music Financial Aid Appeal Form For International Students Undergraduate

Transcription

1 Eastman School of Music Financial Aid Office 26 Gibbs St. Rochester, NY Phone: (585) ; Fax: (585) Eastman School of Music Financial Aid Appeal Form For International Students Undergraduate The Eastman School of Music has an appeal process through which you may request reconsideration of your Eastman need-based aid. By completing this form, you must be able to document a significant change in your family s financial circumstances from what was originally reported on your I-20 Form. Institutional policies require that exceptions are documented and fall within certain parameters. You are also required to complete a CSS Profile for International students at Eastman s CSS Code is Student Name Student ID# Street Address City State Zip Code Phone # ( ) Address Parent Name Street Address City State Zip Code Day Phone # ( ) Address Only one parent or guardian required (if applicable) Academic Information Degree Program: Major: Expected Date of Graduation: Submission of an appeal does not guarantee an adjustment to a student s award. We will complete an initial review of your appeal documentation once all materials are submitted. You will be notified if any additional information is required.

2 Section A: Conditions for Consideration of Additional Eastman Need-Based Assistance The questions below will assist us in understanding why your household is experiencing a decrease in financial resources. Please complete all sections that apply to your situation. Loss/Change of job? Which family member experienced a job loss or change in income? Parent (name) Self Spouse (name) 1. Date of change? Reason for reduction/loss: Job Change Reduced Commissions or Overtime Retirement Termination by Employer Other (please specify) Attach most recent pay stub showing new/changed salary. Include last pay stub from any position terminated in Loss of Untaxed income/benefits? (i.e. Child support, housing assistance, etc.) Person receiving the benefit: Parent (name) Student Date of Change? Name of benefit(s) that was/were affected: Amount Received from January 1, 2015 to present Amount Received from present to December 31, 2015 Please attach documentation of changes/loss. 3. Parent s Separation/Divorce or Death of a Parent? Complete this section only if your parents separated or divorced or a parent passed away. For parent separated/divorced: For death of a parent: Which parent do you live with? (name) Date of death: (month/year) Date of separation: (month/year) Surviving Parent (name) Date of divorce: (month/year) Attach explanation of separation of assets, child support or alimony, if applicable. 4. Unusually High Medical/Dental Expenses? Write in the amount paid out-of-pocket in 2014 for medical and dental expenses. Do not include amounts reimbursed by insurance. Total Paid in 2014: $ Total Expected to Pay in 2015: $ Reason for Expenses: Permanently Disability Chronic Illness Other (specify) Attach a detailed explanation of the reported expenses and attach documentation when available. For permanent disability or chronic illness, please have a physician complete Section D. 2

3 Section B: Income/Expenses In order to fully assess your family s financial situation, we will need some additional information. Please provide monthly estimates (in US currency) for the following income sources and expenses. ENTER 0 OR N/A WHERE APPROPRIATE. DO NOT LEAVE ANY ITEM BLANK. HOUSEHOLD INCOME RECEIVED Earnings from Work Student Spouse name (if applicable) Parent 1 (name) Parent 2 (name) Interest/Dividend Income Pension/Retirement Unemployment Benefits Severance Pay Disability Benefits Social Security Child Support/Alimony Public Assistance Support from Family/Friends HOUSEHOLD EXPENSES MONTHLY ESTIMATE MONTHLY ESTIMATE Mortgage/Rent School/Property Tax Utility Bills Groceries Childcare Auto Payments Auto Insurance Other Insurance Medical/Dental Expenses Credit/Loan Payments Phone/Cell/Cable Other 3

4 CURRENT ASSET INFORMATION CURRENT VALUE CURRENT DEBT Parent Balance of Cash, Savings & Checking Accounts Investments Home Other Real Estate Business Student Balance of Cash, Savings & Checking Accounts Investments Other Real Estate, if applicable Business, if applicable HOUSEHOLD INFORMATION Number of Family Members Living in Parents Home? Number of Family Members Attending College? Age of the Oldest Parent (Mother or Father)? Section C: Other Information Needed Copy of your Passport Copy of your VISA Copy of your I-94 Copy of your most recent I-20 If the reason for this appeal is due to a change in your family s financial circumstances, then we will also need: Copy of most recent Tax Return or Yearly Wage Statement Copy of two most recent pay checks Copy of most recent bank statements If the Sections provided do not allow you to fully explain the circumstances for this appeal, please attach a supplementary letter to provide additional information. 4

5 Section D: Physician s Certification Instructions for physician: Please complete and sign this form to certify that (name of patient) is temporarily totally disabled has been diagnosed with a chronic illness other You may complete this form only if you are a doctor of medicine or osteopathy legally authorized to practice. Sign the certification only if the person diagnosed is unable to work and earn money for at least 60 days in order to recover from an injury or illness. Provide all requested information (you may attach additional pages). Report dates as month-dayyear. The disabled person became unable to work, attend school or required continuous nursing care on - -. The disabling condition or care is expected to continue until - -. Diagnosis of the disabled person s present medical condition (please describe the condition do not use abbreviations or insurance codes): If different from the date you provided above, when did the disabled person s injury or illness begin? - - I certify that, in my best professional judgment, the person identified is unable to work and earn money for at least 60 days because of a medically determinable impairment. I am a doctor of medicine or osteopathy legally authorized to practice. Physician s Name (printed): Telephone #: Address: City, State, Zip Code: Physician s Signature: Date: Section E: Student Certification By signing below, I affirm that the data contained on this form is true and complete to the best of my knowledge. Upon request, I will provide documentation to substantiate the information provided. Also, I understand that the Eastman School of Music has the authority to verify all information reported on this document. Student Date Parent (or Spouse) * Date *Both the student and a parent (or spouse of student) must sign for the process to continue PLEASE RETURN THE COMPLETE APPLICATION TO: FINANCIAL AID OFFICE, EASTMAN SCHOOL OF MUSIC 26 GIBBS STREET, ROCHESTER, NEW YORK FOR OFFICE USE ONLY: APPROVED DENIED SIGNATURE DATE 5