2014-2015 Change Of Circumstance Form Page 2
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22014-2015 Change of Circumstance Form
Circumstance:
Required Documentation
Deceased
Name of deceased: ____________________________
Date of Death: ____/____/______
Please Provide:
Documentation of any life insurance benefits
Date life insurance proceeds received: ____/____/_____
Copy of death certificate
Life insurance payout received for 2013: $___________
Copy of most recent pay stub (if applicable)
Life insurance payout received for 2014: $ ___________
2013 W2(s)
Life insurance payout remaining for 2014: $ __________
2013 Signed Tax Return (1040/A/EZ)
Date Social Security began: ____/____/______
Gross monthly social security: $____________________
Disability
Name of person receiving disability related benefits:
__________________________________
Please Provide:
Copy of most recent pay stub in 2014
Date of Disability: ____/____/______
Documentation of Worker’s Compensation
Amount earned in 2014 prior to disability: $_______________
Benefits in 2014
Documentation of Disability Benefits in 2014
Date worker’s compensation or other disability payments
2013 W2(s)
began: ____/____/______
2013 Signed Tax Return (1040/A/EZ)
Weekly amount of worker’s compensation or other disability
payments: $________________________
These payments are: Taxed Untaxed
Date Social Security began: ____/____/______
Gross monthly social security: $____________________
Anticipated date of return to work ____/____/______
Gross weekly salary $______________________
Other
Name of person who lost income:
Please attach a separate page explaining in detail why
______________________________________________
your estimated 2014 income will be less than your
2013 income.
Effective Date of Loss: ____/____/______
Estimated income received in 2014 from:
Work: $______ Other Taxable: $________ Untaxed: $________
Estimate income remaining to be earned in 2014 from:
Work: $______ Other Taxable: $________ Untaxed: $________
Certification and Signature
I certify that the information provided is true and correct to the best of my ability. If the student is dependent, at
least one parent must sign and date. If the student is married, the spouse’s signature is optional.
______________________________________________ __________
Student’s Signature
Date
______________________________________________ __________
Parent’s/Spouse’s Signature
Date
Financial Aid Office |
finaid@centenarycollege.edu
|
400 Jefferson Street | Hackettstown, NJ 07840 | (T) 908-852-1400 ext. 2350 | (F) 908-813-2632
CHGCIR Updated 20140324
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