Supplemental Data Worksheet - Benedictine College
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22016-2017 SPECIAL CIRCUMSTANCES WORKSHEET
02.11.2016
Directions: Prior to completing this review, your 2016-17 FAFSA info must be
verified using the V1 verification forms located on the Benedictine website,
along with 2015 IRS Tax Transcripts (NO TAX RETURNS ACCEPTED).
Failure to provide will result in delays in the review process.
_____________________________________________________________________________________________________________
Student’s Last Name
First Name
MI
SSN
_________________________
Student ID #
1.
If your parents are currently making payments for Parent PLUS loans, please provide payment information indicating the
monthly payments made during the 2015 calendar year. Include copy of payment stubs or lender account activity.
$_________________
_____________________________________________________________________________
2.
If you or your parent(s) paid tuition expenses at a private elementary, secondary or home school in 2015, please list the
student(s), school(s), and the amount paid for each child. Include an itemized statement from the school, parish or for
the home school expenses.
$_________________
_____________________________________________________________________________
$_________________
_____________________________________________________________________________
$_________________
_____________________________________________________________________________
3.
If you or your parent(s) paid medical or dental expenses “out of pocket” in 2015 not covered by insurance or reimbursement,
list amount from Schedule A-Itemized Deductions, Line 1. Include a copy of Schedule A or an itemized statement from your
health care provider. Insurance premiums & Cafeteria 125 plans or prepaid medical accounts are NOT allowed.
$_________________
_____________________________________________________________________________
$_________________
_____________________________________________________________________________
$_________________
_____________________________________________________________________________
4.
If you or your parent(s) have recently become unemployed, or there has been a change in income, write a brief synopsis of
the situation estimating income for calendar year 2015. Submit a copy of (1) the separation agreement, (2) parent(s) or
student’s most recent pay-stub(s) showing annual 2015 earnings-to-date, and (3) current pay-stub from new job.
$_________________ Anticipated 2016 Annual Earnings
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5.
$_______________ If the student is currently working during high school and expects to quit their job due to college
enrollment, the summer 2015 earnings will be evaluated as a better representation of the students ability to contribute toward
their education. Please submit a copy of the pay-stubs from the beginning and end of the summer.
6.
If your family is maintaining two households due to employment relocation or family care obligations, write a brief synopsis
of the situation and provide annual costs associated with the situation and documentation of such expenses for 2015.
$__________________ Annual Cost
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
OVER
COMPLETE PAGE TWO PLEASE
Page 1
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