Number. Address (street or P.O. box number, city, state, ZIP)

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1 University of Minnesota Crookston DEPENDANT SPECIAL CIRCUMSTANCE APPEAL Academic Year Office of Financial Aid & Scholarships University of Minnesota Crookston 170 Owen Hall, 2900 University Ave. Crookston, MN Phone: 218/ Fax: 218/ According to federal laws and regulations, a family s 2015 income is used to assess financial need for the school year. If a family s income is lower due to special circumstances, a financial aid administrator may be able to use the 2016 income or projected income to assess financial need. Please provide information regarding your reduction in income by completing this form. Student Information Student s Name (last, first, middle initial) Birthdate Social Security Number Student ID number Address (street or P.O. box number, city, state, ZIP) Phone Number This application should be used by dependent students and their parents whose financial situation has changed and 2015 tax information does not accurately reflect the family s current financial condition. This change may be due to loss of job, separation or divorce, disability, death, unusual expenses, or other circumstances. As you may be aware, financial aid eligibility for is calculated based on the student s and parent s 2015 federal income tax returns. Therefore, before a request for special consideration will be reviewed by UMC, the student must make an application for federal financial aid using the FAFSA and using 2015 tax information. After completing and mailing the FAFSA, you may then complete this application if you and your family wish to apply for the review of your special circumstances. Return this application to the Office of Financial Aid and Scholarships, 170 Owen Hall, 2900 University Ave, Crookston, MN

2 NEEDED DOCUMENTATION Depending on the circumstance, various documentation may be needed to support your situation. For the financial aid office to approve a request for special consideration, documentation must be thorough and complete. It is the student and parent s responsibility to provide all needed documentation to support their special circumstance. Provide any documentation you feel would help support your situation. Please check which situation applies to your circumstance and provide the necessary documentation: For ALL circumstances A detailed statement describing the situation. On an additional piece of paper, describe in detail the situation which is causing you to apply for special consideration. Be concise, and include the date when the situation you are describing occurred. Date when situation described occurred: Month _ Day Year For loss of job A letter from the former employer or other documentation of loss of job and a letter from a pastor, counselor, accountant, attorney or other professional attesting to the parent s loss of job. This situation must be in effect for at least three months before a change in circumstances will be considered. For unusual medical expenses A detailed explanation of the situation, copies of all expense receipts and insurance papers, and an itemized listing showing type of expense and the total amount you have paid. Our office assumes you have health insurance so only costs not covered by insurance or another agency may be considered. These expenses must be at least $2,200. For loss of unemployment benefits A statement from the Employment commission showing amount of benefits received, dates received, and date terminated. For divorce or separation Copy of divorce documents or notarized statement from both parents attesting to; the separation, date of separation or divorce, and a separation of income statement (including 2015 Federal Tax return and W-2 s). For disability - Statement from physician as to nature and condition of disability and date disability began. For death A copy of official death certificate. Other -Please submit documentation that you believe is appropriate for your situation. It is impossible to list all situations and the documentation needed. The financial aid office reserves the right to request additional documentation at its discretion. You will be notified if other items are needed.

3 Section 1. Student Information Name Student ID Date Address Phone City State Zip List all family members included on your FAFSA (If you need additional space, you may add more family members in your personal statement). Relationship to College attended from July Social Security Name Birth Date Student 1, 2016 to June 30, 2017 Number University of Minnesota Self Crookston Father Mother Sibling Section 2. Income Source Table January 1 through December 31, 2016 Income earned from work by father (wages, salary, & tips) Actual 1/1/16 - today Estimated Today - 12/31/16 Total Actual+Estimated Income earned from work by mother (wages, salary, & tips) Income earned from work by student (wages, salary, & tips) Business, farm, or rental income Interest/dividend income, specify below by source & value: Unemployment compensation Capital gains Spousal maintenance Child support Welfare benefits (such as AFDC or TANF) Veterans benefits Social Security benefits (including SSI) Workers compensation Short-term or long-term disability benefits Severance pay Withdrawal from retirement account Other (e.g. pension, annuity, housing allowance, bonuses)

4 SECTION 3: FAFSA Additional Information Tables, Calendar Year 2015 Items to review. We need these items to be reviewed if your family reported dollar amounts on lines 91 and 92 of your 2016 FAFSA. Enter a $0 next to any item that does not apply to your parents. Please report annual amounts. Q91. Parents 2015 Additional Financial Information (Enter the amounts for your parent[s]) FAFSA 2016 Estimate a.education credits (Hope & Lifetime Learning tax credits) from IRS Form 1040-line 49 or 1040A-line 31. b. Child support paid because of divorce or separation or as a result of a legal requirement. Don t include support for children in your parents household, as reported in question 72. c. Your parents taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and assistantships. d. Your parents taxable student grant and scholarship aid reported to the IRS in your parents adjusted gross income. Includes AmeriCorps benefits (awards, living allowances and interest accrual payments), as well as grant and scholarship portions of fellowships & assistantships. e. Combat pay or special combat pay. Only enter the amount that was taxable and included in your parents adjusted gross income. Do not enter untaxed combat pay reported on the W-2 (Box 12, Code Q). f. Earnings from work under a cooperative education program offered by a college. $ $ Q92. Parents 2015 Untaxed Income (Enter the amounts for your parent[s]) FAFSA 2016 Estimate a. Payments to tax-deferred pension and 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. b. IRA deductions and payments to self-employed SEP, SIMPLE, Keough, and other qualified plans from IRS Form 1040-line 28 + line 32 or 1040A-line 17. c. Child support received for any of your children. Don t include foster or adoption payments. d. Tax exempt interest from IRS Form 1040-line 8b or 1040A-line 8b. e. Untaxed portions of IRA distributions from IRS Form 1040-lines (15a 15b) or 1040A-lines (11a 11b). Exclude rollovers. If negative, enter a 0 here. f. Untaxed portions of pensions from IRS Form 1040-lines (16a 16b) or 1040A-lines (12a 12b). Exclude rollovers. If negative, enter a 0 here. g. 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 a basic military allowance for housing. h. Veterans noneducation benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA Educational Work-Study Allowances. i. Other untaxed income not reported in items 92a through 92h, such as workers compensation, disability, etc. Don t include student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social Security benefits, Supplemental Security Income, Workforce Investment Act educational 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.

5 We certify, by signing below, that all of the information reported on this application is true and complete to the best of our knowledge. If asked by a financial aid administrator, we agree to provide proof of the information we have reported, including but not limited to copies of 2015 federal tax returns, W-2 forms and schedules. We also understand that failure to provide any documentation requested will result in denial of this application. Certification You must sign this form certifying that the information you provided is true. Misrepresentation of facts in connection with this form may be sufficient cause, in and of itself, for cancellation or repayment of financial aid, whenever discovered. Student Signature Father s Signature Mother s Signature OFFICE USE ONLY Action taken FAA signature Date New AGI: New Father income Untaxed income Old EFC: New tax paid New mother income New student income New EFC: Comments Student notified on Method of notification