University of Texas at Tyler Special Circumstances Request Independent Student

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1 University f Texas at Tyler Special Circumstances Request Independent Student Student Name: ID#: Sectin I. In accrdance with Federal regulatins, student and spuse 2014 incme is used t determine student eligibility fr financial aid fr the academic year. Hwever, there are special circumstances under which we may be able t recalculate student eligibility fr financial aid using student and spuse 2015 incme r adjusted 2014 incme. The special circumstances which we may cnsider include: As f tday, student r spuse have had a lss f incme such as alimny payments, child supprt, scial security benefits, and pensins/annuities/wrker s cmpensatin As f tday, student r spuse is unemplyed Student s cmbined 2015 incme will be significantly lwer than the 2014 incme Unusually high medical/dental expenses (in excess f 10% AGI) Since cmpleting the FAFSA, student r spuse is expecting the birth f a child r an additin t the husehld nt included in the FAFSA infrmatin Student r spuse meeting at least ne f the circumstances listed abve may cmplete the apprpriate sectin(s) f this frm including the Certificatin sectin. Please include a written narrative explaining yur situatin. Submissin f this frm will require riginal FAFSA infrmatin be verified and adjustments made if there are any discrepancies. This culd cause an adjustment t current aid awarded. Failure t turn in the required verificatin dcuments will result in cancellatin f financial aid awards. The Special Circumstances frm will NOT be reviewed until verificatin f the riginal FAFSA is cmplete. Please submit all required dcumentatin at the same time. Submissin f this request and all required dcuments des nt guarantee the request will be granted. Sectin II. The Financial Aid Office will nly cnsider reductins in incme fr the circumstances listed in Sectin I f this frm. It is ur plicy nt t cnsider a reductin in incme fr the fllwing: If yu already have an EFC (estimated family cntributin) f zer Unusual expenses related t persnal living (e.g. wedding expenses, credit card bills, hme mrtgage r schl lan payments, car payments, legal expenses, ther miscellaneus cnsumer item expenses) Families with reductins prcessed in the academic year that grssly underestimated their 2014 incme One year bnus incme such as lttery r gambling winnings Reductins in vertime pay (this will be reflected n the fllwing year s aid applicatins) Reductins in incme resulting frm bankruptcy prceedings Medical and dental expenses that ccurred in 2014 that are nt dcumented n yur 2014 federal tax returns If the reasn yu are requesting a review is listed in this sectin, d nt cmplete this frm. If yu are nt certain whether r nt yur situatin may be cnsidered fr a review, please cntact ur ffice at (903) t schedule an appintment with a Financial Aid Cunselr.

2 Student Name: ID# Required Dcumentatin fr all requests: Detailed narrative f the reasn(s) fr yur request Signed Verificatin Frm (attached) Cpy f student (and spuse if applicable) 2014 tax return transcript Cpy f student s 2014 W2s/1099s Sectin III: T determine if any adjustments can be made t the student s financial aid file, please CHECK the apprpriate CIRCUMSTANCE belw and return this frm with the applicable dcumentatin. Please nte that additinal dcumentatin may be requested. LOSS OF INCOME Benefits/Wrkman s Cmpensatin Benefits Ended Prvide fficial dcumentatin: Letter frm previus emplyer(s) stating last date f emplyment and year-t-date earnings. If last date f emplyment was in 2013, year-t-date earnings are nt required. Letter frm current emplyer with emplyment start date, yearly salary and yeart-date earnings. Mst recent cpy f year-t-date benefits statement fr unemplyment/ A cpy f the mst recent pay stubs with year-t-date earnings clearly shwn. If year-t-date earnings are nt shwn, submit a letter frm emplyer. Yu MUST cmplete Sectin IV f this frm. Alimny Ended Scial security benefits/pensins and/r annuities/child Supprt Ended Prvide curt dcumentatin indicating date f terminatin and Year t Date amunt received. D NOT cmplete Sectin IV. Prvide fficial dcumentatin frm the apprpriate entity that yu were receiving yur benefits indicating beginning and ending dates f the benefit and the Year t Date amunt received. D NOT cmplete Sectin IV f this frm. DIVORCE/SEPARATION/DEATH OF A PARENT Divrce r Separatin Since cmpleting the FAFSA, yu have becme divrced r separated. Prvide legal dcumentatin f the date f divrce r separatin, cpies f all 2014 W-2s, 1099s and 2014 tax return transcript. Yu MUST cmplete Sectin IV f this frm. If yu were divrced r separated prir t cmpleting the FAFSA, please cntact ur ffice and d NOT submit this frm. Death f a Spuse Since cmpleting the FAFSA, yur spuse is n lnger living. Prvide dcumentatin f the date f death (cpy f death certificate). D NOT cmplete Sectin IV f this frm.

3 Student Name: ID# UNUSUALLY HIGH MEDICAL/DENTAL EXPENSES Medical/Dental Expenses in excess f 10% f AGI (Adjusted Grss Incme) The Student r dependent family member has incurred excessive medical/dental expenses in 2014 that were nt cvered by insurance. Elective medical prcedures will nt be cnsidered. Please prvide cpy f yur 2014 tax return transcript and Schedule A. If yu did nt file a Schedule A, yu will need t submit cpies f statements frm each applicable entity (i.e.: pharmacy, hspital) shwing what was paid ut f pcket. The family member(s) wh incurred these must be receiving at least 50% supprt frm yur parent(s). Supprt includes rent, fd, electric, clthing, etc. D NOT cmplete Sectin IV f this frm. BIRTH OF A CHILD/ADDITION TO HOUSEHOLD Birth f child/additin t husehld Since cmpleting the FAFSA, yu are expecting/have welcmed the birth f a child r an additin t the husehld nt included in the FAFSA infrmatin, please prvide a cpy f the birth certificate r signed and dated letter frm physician giving current status and expected date f birth; r a detailed statement explaining the additin if nt fr the birth f a child. The child must be receiving at least 50% supprt frm yu in rder t be included as a dependent. Supprt includes rent, fd, electric, clthing, etc. D NOT cmplete Sectin IV f this frm. Cmments:

4 Student Name: ID# Sectin IV: Please prvide anticipated incme fr the entire calendar year D nt list hurly wage rates but instead cmpute what will be earned fr the year. List all incme received frm January 1, 2015 until nw in the first clumn and estimate the amunts t be received frm nw until December 31, 2015 in the secnd clumn. Ttal the first and secnd clumns. D nt leave any bxes blank, if it des nt apply, please indicate 0. INCOME FOR JANUARY 1, 2015, TO DECEMBER 31, 2015 Independent Student and Spuse ACTUAL + ESTIMATED = TOTAL (ACTUAL + Taxable Incme t Date /_ /_ Date /_ /_ t 12/31/15 ESTIMATED COLUMNS) Student s incme frm wrk Spuse s incme frm wrk Taxable interest incme Taxable pensins/annuities Unemplyment Cmpensatin All Taxable prtins f Scial Security fr Husehld Alimny/Spusal Supprt Other Ttal ACTUAL + ESTIMATED = TOTAL (ACTUAL + Untaxed Incme t Date /_ /_ Date /_ /_ t 12/31/15 ESTIMATED COLUMNS) Husing, Fd, and ther living allwances (Dn t include value f military husing/allwance) Veterans nn- educatin benefits Untaxed pensins/annuities/ira cntributins Wrker s cmpensatin/disability All Child supprt received in the husehld IRA/KEOGH distributin Tax exempt interest incme Other_ (Wrker s cmp, disability, life insurance etc.) Ttal Student Name: ID#

5 ACTUAL + ESTIMATED = TOTAL (ACTUAL + Additinal Financial Infrmatin t Date /_ /_ Date /_ /_ t 12/31/15 ESTIMATED COLUMNS) Educatin Credits (Hpe and Lifetime Learning tax credits) IRS Frm 1040 line 50 r 1040A line 33 All Child Supprt Paid ut fr nn-husehld members Taxable Earnings frm Federal Wrk Study r ther need-based wrk prgrams Earnings frm wrk under Cperative educatin prgram ffered by a cllege Schlarships and Grants t be reprted n 2014 Incme Tax Return Taxable Cmbat Pay r Special Cmbat Pay Ttal Please review t insure yu have included all REQUIRED dcuments and infrmatin is cmplete. Verificatin f yur student s riginal FAFSA infrmatin will be perfrmed and adjustments made if there are any discrepancies fund, regardless f whether this Special Circumstance is apprved. This culd impact yur student s current financial aid awards. Sectin V: Certificatin By the signatures belw, everyne signing this frm is certifying that all infrmatin n the frm is crrect and that everyne will prvide the required dcuments t verify the infrmatin. If yu purpsely give false r misleading infrmatin n this frm yu may be referred t the Inspectr General, which culd result in being fined, sent t prisn r bth. Submissin f this request and all required dcuments des nt guarantee that the request will be granted. Student Signature Date Signed Spuse Signature (ptinal) Date Signed This frm may be returned by , fax, r mail: UT Tyler, Enrllment Services Center 3900 University Blvd., Tyler, TX 75799

6 The University f Texas at Tyler Independent Verificatin Frm Student s Name: ID #: Yur financial aid file will nt be cnsidered cmplete until all required dcumentatin has been submitted and prcessed. Yur Free Applicatin fr Federal Student Aid (FAFSA) was selected fr verificatin. The law states (CFR, Part 668) that we are required t cnfirm the accuracy f infrmatin yu reprted n yur FAFSA. T verify that yu prvided crrect infrmatin a Financial Aid Cunselr will cmpare yur FAFSA with the infrmatin n this wrksheet and with any ther required dcuments. If there are differences, yur FAFSA infrmatin may need t be crrected. Yu must cmplete and sign this wrksheet, attach any required dcuments, and submit all dcuments t the Enrllment Services Center. If clarificatin is needed, the Financial Aid Cunselr may ask fr additinal infrmatin by cntacting yu via yur Patrit . Family Husehld Infrmatin Hw many peple are in yur husehld? Dependent Students Include: Yurself Yur spuse (if married) Yur children r ther dependents if they live with yu and yu will prvide mre than half their supprt between July 1, 2015 and June 30, Name f Family Member Age Relatinship t Student (Self, spuse, sn, etc.) Student - SELF Attach an additinal sheet with name, age, and relatinship if there are mre than 6 members in yur husehld.

7 Student s Name: ID#: Family Cllege Attendance Infrmatin Hw many peple in yur husehld will be cllege students between July 1, 2015 and June 30, 2016? Always include yurself as a cllege student. Yu may include thers nly if they will attend, at least half-time in , in a prgram that leads t a cllege degree r certificate, and are listed in the husehld infrmatin abve. D NOT include students enrlled in high schl attending cllege fr dual credit. Name f Family Member Name f Cllege Will be Enrlled at Least Half Time Student- UT Tyler YES NO YES YES YES YES NO NO NO NO STUDENT/SPOUSE INCOME FOR 2014 I and/r my spuse (if applicable) filed a 2014 Federal Incme Tax Return. Please submit a cpy f the tax return transcript(s). Yu may request a Tax Return Transcript at r by calling I and/r my spuse are nt required t file and will nt file a 2014 Federal Incme Tax return. Please check the apprpriate reasn: I and/r my spuse were nt emplyed and had n incme earned frm wrk in I and/r my spuse wrked in 2014, but did nt earn enugh t file. Please cmplete the table belw* and submit all W2s/1099s. *Nntax Filers nly Name f Family Member 2014 Amunt IRS W-2 Emplyer s Name Earned Attached? Suzy s Aut Bdy Shp (example) $2, Yes

8 Student s Name: ID#: Supplemental Nutritin Assistance Prgram (SNAP) Cmplete this sectin if smene in the student s husehld received benefits frm the Supplemental Nutritin Assistance Prgram r SNAP (frmerly knwn as fd stamps) any time during the 2013 r 2014 calendar years. One f the persns listed n this wrksheet received SNAP benefits in 2013 r If requested by a financial aid cunselr, I will prvide dcumentatin f the receipt f SNAP benefits during 2013 and/r Child Supprt Paid Must Be Verified Cmplete this sectin if yu r yur spuse paid child supprt in I have indicated belw the name f the persn wh paid the child supprt, the name f the persn t whm the child supprt was paid, the names f the children fr whm child supprt was paid, and the ttal annual amunt f child supprt that was paid in 2014 fr each child. If asked by a financial aid cunselr, I will prvide dcumentatin f the payment f child supprt. If yu need mre space, attach a separate page that includes yur name and ID# at the tp. Amunt f Name f Persn Wh Paid Name f Persn t Whm Name f Child fr Whm Child Supprt Child Supprt Child Supprt was Paid Supprt Was Paid Paid in 2014 Marty Jnes(example) Chris Smith Terry Jnes $6, Certificatin and Signature WARNING: If yu purpsely give false r misleading infrmatin n this wrksheet, yu may be fined, sentenced t jail, r bth. By signing this frm I certify that all infrmatin n the frm is crrect and that I will prvide the requested dcument(s) t verify the infrmatin. Student s Signature Date This frm may be returned by , fax, r mail: UT Tyler, Enrllment Services Center 3900 University Blvd., Tyler, TX 7579

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