Indiana University Northwest Grant Form printable pdf download

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INDIANA UNIVERSITY NORTHWEST

Office of Financial Aid and Scholarships

Special Circumstances Appeal Form - 2015-2016 Academic Year

Name (Print) __________________________________ University ID Number: ___________________________

Telephone Number: ______________________________ Email: _________________________

Have you ever submitted a Special Circumstances Appeal Form in the past? Yes_____

No______

Purpose

The Special Circumstances Appeal allows the consideration of 2015 projected income for financial aid based on documented

unusual circumstances. The unusual circumstances may include one or more of the following:

Uninsured medical/dental cost

Decreased income

Loss of Benefits or untaxed income

Change in marital status

Requirements

•

2015-2016 FAFSA with a valid Estimated Family Contribution (EFC)

•

All Required Documentation listed for each category of your application

•

Submit a copy of 2014 Federal Income Tax Transcript, all W-2’s, and the appropriate household form.

or by calling 1-800-908-9946.

•

Provide a detailed written statement explaining your special circumstances

a. Student/Spouse (Independent students must submit individual signed statement.)

b. Parent (Dependent students must submit parent signed statement)

Completing the following sections may reduce your Expected Family Contribution (EFC). **Items 2, 3, and 4 require the

completion of the worksheet on page 2 of this application.

1) Uninsured medical/dental costs paid between August 2014 and May 2015

Required Documentation: Proof or estimate, on letterhead of physician, of expense(s), or receipt(s). Do not include routine check-

ups or insurance premiums.

Uninsured medical expense

$_____________

________________________________________

Monthly payment

$_____________

Uninsured’ s Full Name &

Relationship to you

Date Payments Begin

_____________

**2) Decreased income between 2014 and 2015 (loss of business, decrease in wages or salary)

Required Documentation: Estimated income amounts from all sources for 2015, unemployment benefits (if applicable),

last pay stub(s), letter from former employer and the completed worksheet on page 2.

After January 31, 2016 all

2015 W-2’s are required.

**3) Loss of benefits or untaxed income between 2014 and 2015

(worker’s compensation, disability, 529 distribution, Pension, child support)

Required Documentation: Proof of the loss in benefit(s) –letter from the benefit source, document reporting the amount

of benefit(s) received to date, estimated income/benefit from all sources for 2015 and the completed worksheet page2.

**4) Separated, divorced, or widowed since filing the FAFSA

Required Documentation: Proof of lost income, divorce decree, notarized statement on separation which includes your

separated spouse’s current address, death certificate and the completed worksheet on page 2 reporting 2015 income

amounts from all sources…this would include amounts received to date and an estimate of income amounts anticipated

through the remaining portion of the year.

Please Circle one of the following:

Separated

Divorced

Widowed

____________________

MM/DD/YYYY

Please return the completed form to:

Revised 03/05/15

Office of Financial Aid and Scholarships • 3400 Broadway, Rm 111 •

Gary, IN 46408-1197

Phone: (219) 980-6778

• Fax: (219)981-5622

• Email: finaidnw@iun.edu

Indiana University Northwest Grant Form

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