INDIANA UNIVERSITY SOUTHEAST INDEPENDENT STUDENT Special Circumstances Appeal Form Academic Year/Summer

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1 INDIANA UNIVERSITY SOUTHEAST Special Circumstances Appeal Form Academic Year/Summer Office of Financial Aid Indiana University Southeast 4201 Grant Line Road University South 105 New Albany, IN (812) Fax (812) Web site: OneStart: Appeal and all required documentation submitted no later than 30 days before the last day of the semester. Process: Appeals are reviewed by a committee and are subject to federal guidelines. If approved, changes are submitted to the U.S. Department of Education (FAFSA) and financial aid will be adjusted once approved. We cannot make adjustments without documentation and if the student makes these adjustments to the FAFSA on their own those changes will be rejected or trigger additional verification, which could result in the loss of existing eligibility for aid. Appeals may be closed without a ruling if the requested changes would not affect the student s financial aid. Required forms can be found online at STEP 1: Contact Information and Acknowledgement (print): IU Student ID: _000- Phone Spouse Name (print): READ and SIGN: I give permission to the Financial Aid office to verify any information I provide. I understand that this verification may include a request for copies of my tax and/or financial documents. I certify that all of the information provided for this appeal is correct to the best of my knowledge. I understand that if I purposely give false or misleading information, I am liable for cancellation or repayment of all or part of my financial aid. I acknowledge that all communication regarding this appeal will be sent to my (the student) IU account. : : STEP 2: Verification Before adjustments can be made for special circumstances the information you submitted on the FAFSA must be checked for accuracy. Verification forms are included with the special circumstance form for your convenience and listed below. In addition to other documentation noted on page 2, the student (and spouse if applicable) must provide SIGNED COPIES of the following. INDEPENDENT SPECIAL CIRCUMSTANCE form (this form) INDEPENDENT household form Student federal tax return (with signature added) and W-2 s OR Spouse federal tax return (if student and spouse did not file jointly) and W-2 s Student NON-TAX FILER form if the student did not file. CHILD SUPPORT FORM IF someone listed on the Household Form PAID child support in the previous tax year. SNAP FORM IF someone listed on the Household Form received SNAP benefits within the last two years OR has recently applied for or begun receiving SNAP benefits this year.

2 Student name: Page 2 STEP 3: Special Circumstance Documentation: Select all that apply. INCOME: Student and/or spouse expects a significant decrease in income from the previous year. Person(s) who lost income: student spouse Job change/loss was: voluntary involuntary Documentation (include all that apply): Job loss: Unemployment Benefit Statement, severance package and/or letter from employer confirming job loss Job change: Most recent pay stub of new job and proof of start date, last pay stub of previous job and proof of end date Retirement/Disability: Disabilities Benefit Statement, Retirement or Social Security Benefit Statement Returning to school quit or reduced hours: most recent paystub, letter showing date of resignation/job loss or reduction in hours MEDICAL EXPENSES: Family paid extraordinary non-reimbursed medical costs during previous year. Documentation: Proof of all non-reimbursed medical and/or dental expenses paid during the previous year for anyone listed on the Household Information form, including insurance premiums. Only include expenses actually paid. If you filed a federal 1040 tax return and you itemized your tax deductions, the amount listed on your 1040 Schedule A form can be used and a copy of this form will be sufficient evidence. If you did not itemize, provide an estimate of your expenses. A simulation will be run to determine if your expenses are high enough to make a difference in your aid and if so will notify you of the documentation we will require. Estimated unreimbursed medical expenses paid in previous year: NATURAL DISASTER: Family has paid extraordinary non-reimbursed housing expenses during the previous year due to a disaster. Examples include tornado, flood, fire, storm damage. Please provide an itemized statement showing expenses incurred and payments made as well as documentation of the circumstance. Documentation: Insurance claim/denial Receipts for damage and repair costs as well as extra housing expenses paid in previous year Estimated unreimbursed additional housing expenses paid in previous year: MARITAL STATUS: Student has become separated, divorced, widowed or student has gotten married since filing the FAFSA. (It is not always in the best interests of the student to appeal after a change in marital status. See an advisor first.) Student became separated divorced widowed married on: (date) Copy of the marriage certificate or proof of other changes in marital status (divorce or separation papers, obituary) A signed copy of spouse s previous year W-2 s and also their tax return if you did not file jointly If the student s last name has been changed through the Social Security Administration a copy of the new SS Card Number in Household: Number of members in the household has increased since filing the FAFSA. Refer to the Independent Household Information form to know who to include in the household. Documentation: Show all members on the Independent Household Form requested in Step 2. Number in College: Number of members in the household attending college has increased since filing the FAFSA. Must be attending at least ½ time and working toward a college degree or certificate. Documentation: Indicate college(s) on the Independent Household Form requested in Step 2. Copy of unofficial transcript showing enrollment and degree objective if not an IU student.

3 2013 NON TAX FILER FORM Based on the information provided on your Free Application for Federal Student Aid (FAFSA) you, the student (and, if married, your spouse), indicated you will not and are not required to file a 2013 income tax return with the IRS. Check the box that applies: I (and, if married, my spouse) were not employed and had no income earned from work in I (and/or my spouse, if married) were employed in 2013 and have listed below the names of all employers, the amount earned from each employer in 2013 and whether an IRS W-2 form is attached. Attach copies of all 2013 IRS W-2 forms issued to you or your spouse, if married. List every employer even if they did not issue an IRS W-2 form. Employer s Name Student Spouse 2013 Amount Earned IRS W-2 Issued by employer IRS W-2 Attached Susie s Auto Body Shop (example) 2,000 (example) Yes (example) Yes (example) Certification and Signatures: I certify that all of the information reported is complete and correct. The student must sign and date the form. Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail, or both.

4 HOUSEHOLD INFORMATION FORM Independent Student Family Information: List below the people in your household. Include: Yourself. Your spouse, if you are married. Your children, if any, if you will provide more than half of their support from July 1, 2014 through June 30, 2015, or if the child would be required to provide your information if they were completing a FAFSA for Include children who meet these standards, even if they do not live with you. Other people if they now live with you and you provide more than half of their support and will continue to provide more than half of their support through June 30, Please Note: This does not include foster children who may reside in the household. Include the name of the college for any household member who will be enrolled at least half-time in a degree, diploma, or certificate program any time between July 1, 2014, and June 30, Full Name of Household Member Age Relationship to of College Self Indiana University Spouse Certification and Signatures: I certify that all of the information reported is complete and correct. The student must sign and date the form. Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail, or both.

5 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM FORM Based on the information provided on your Free Application for Federal Student Aid (FAFSA) you must complete, sign and submit this form. Check the box below that applies to your household. YES - One of the persons included in my household received benefits from the Supplemental Nutrition Assistance Program (SNAP) in 2012 or NO - No one included in my household received benefits from the Supplemental Nutrition Assistance Program (SNAP) in 2012 or According to the FAFSA instructions, the people in your household include: Yourself. Your spouse, if you are married. Your children, if any, if you will provide more than half of their support from July 1, 2014 through June 30, 2015, or if the child would be required to provide your information if they were completing a FAFSA for Include children who meet these standards, even if they do not live with you. Other people if they now live with you and you provide more than half of their support and will continue to provide more than half of their support through June 30, Please Note: This does not include foster children that may reside in the household. Certification and Signatures: I certify that all of the information reported is complete and correct. If asked, I will provide documentation of the receipt of benefits during 2012 and/or The student must sign and date the form. Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail, or both.

6 CHILD SUPPORT PAID FORM Based on the information provided on your Free Application for Federal Student Aid (FAFSA) either you, or if married your spouse, reported they paid child support in 2013 for a child not included in your household. Please indicate below, the name of the person who paid the child support, the name of the person to whom the child support was paid, the names of the children for whom child support was paid, and the total annual amount of child support that was paid in 2013 for each child. Name of Person Who Paid Child Support Name of Person to Whom Child Support was Paid Name of Child for Whom Support was Paid Annual Amount of Child Support Paid in 2013 Marty Jones (example) Chris Smith (example) Terry Jones (example) 6,000 (example) The amount of Child Support Paid reported on the FAFSA was listed in error. I, or if married, my spouse did not pay child support in 2013 for a child not included in our household. Certification and Signatures: I certify that all of the information reported is complete and correct. If asked, I will provide documentation of the payment of child support. The student must sign and date the form. Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail, or both.

7 UNTAXED INCOME FORM Based on the information provided on your Free Application for Federal Student Aid (FAFSA) either you or your spouse, if married, must verify the amount of untaxed income received in Please indicate below, ALL source(s) and amount(s) of untaxed income received in Please list a 0 for item amounts that do not apply. Untaxed Income Type Annual Amount Received in Payments to tax-deferred pension and retirement savings plans (paid directly or withheld from earnings), including, but not limited to, amounts reported on the W-2 forms in Boxes 12a through 12d, codes D,E,F,G,H and S. Don t include amounts reported in code DD (employer contributions toward employee health benefits). 2. Child support received for any of your children. Don t include foster care or adoption payments. 3. Housing, food and other living allowances paid to members of the military, clergy and others (including cash payments and cash value of benefits). Don t include the value of on-base military housing or the value of the basic military allowance for housing. 4. Veterans non-education benefits, such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances. 5. Other untaxed income not reported above, such as worker s compensation, disability, etc. Also include the untaxed portions of health savings accounts from IRS Form 1040 line 25. Don t include extended foster care benefits, student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social Security benefits, Supplemental Security Income, Workforce Investment Act education benefits, on-base military housing or a military housing allowance, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion or credit for federal tax on special fuels. 6. Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form. This includes money that you received from a parent whose financial information is not reported on the FAFSA form and that is not part of a legal child support agreement. Also includes distributions made to the student from a 529 plan that is owned by someone other than you or your parents (such as grandparents, aunts, and uncles). -STUDENT & SPOUSE- (if married) Certification and Signatures: I certify all of the information reported is complete and correct. The student must sign and date the form. Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail, or both.

8 INCOME & ASSET INFORMATION FORM Section 4: Student Income and Asset Information Instructions and Tips: Please complete the information below for the student whose information is reported on the FAFSA. The amounts that you indicate for your income and assets should be the value of your accounts and assets as of the day you filed your FAFSA. Do not double report amounts on this form. All amounts should be reported only once. In cases where items do not apply, please enter a 0. Income & Asset Information As of the day you filed your FAFSA, what was your total balance of cash savings and checking accounts? Student As of the day you filed your FAFSA, what was the net worth of your investments? Include real estate (this does not include the home that you live in) Uniform Transfers to Minors Act (UTMA s) & Uniform Gifts to Minors Act (UGMA s) College savings plans Coverdell Savings Accounts, trust funds, mutual funds, money market funds, & CD s Stocks, stock options, bonds, commodities & precious metals **Note: Do Not include the value of retirement plans (401K plans, pension funds, annuities, and non-education IRA s Keogh plans) As of the day you filed your FAFSA, what was the net worth of your current businesses and/or investment farms? If you own a business that employs more than 100 full-time workers, its net worth should be listed. Include net worth reported for land, buildings, machinery, equipment, & inventories If you own an Investment farm list its net worth here. Include land, equipment, inventory & livestock (Do not include if your family lives on the farm.) Certification and Signatures: I certify all of the information reported is complete and correct. The student must sign and date the form. Warning: If you purposely give false or misleading information on this form you may be fined, be sentenced to jail, or both.