Special Circumstances Request Form (Page 2 of 2) in pdf

Special Circumstances Request Form Page 2

______ DEATH- Your spouse or parent who had earnings in 2014 has passed away

Please supply:



Death certificate



Documentation of deceased 2014 earnings if applicable



Documentation of any death benefits received



Income verification for 2014 including but not limited to Federal Tax return and W2 forms

_____ DISABILITY- You, your spouse, or parent will earn less in 2014 due to a disability

Please supply:



A typed statement with dates explaining how disability effected income



Documentation of 2015 earnings prior to disability



Documentation of benefits received after disability



Income verification for 2014 including but not limited to Federal Tax return and W2 forms

_____ ONE TIME INCOME- You, your spouse, or your parent received a one-time income in 2014 that will not be

received in 2015 and this income was used for extraordinary expenses

Please supply:



A typed statement and documentation explaining and proving what were your “extraordinary expenses”



Documentation of one-time payment



Income verification for 2014 including but not limited to Federal Tax return and W2 forms

_____ LOSS OF TAXABLE OR UNTAXED BENEFIT- You, your spouse, or your parent received a benefit in 2014 that they

will not receive or that was lost during 2015

Please supply:



Documentation that benefit was terminated and documentation of benefit amount received in 2014



Income verification for 2014 including but not limited to Federal Tax return and W2 forms

_____ OUT OF POCKET MEDICAL EXPENSES- You or your parent paid medical bills in 2014 that were not covered by

insurance

Please supply:



Schedule A of federal tax return



Income verification for 2014 including but not limited to Federal Tax return and W2 forms

Special Circumstances Request Form Page 2