Fillable Special Circumstance Form 2014-2015 - Augustana College (Page 2 of 2) in pdf

Section 4. Income/Resource Reduction or Nonrecurring Income/Resource

Documentation required: ►Your parent’s 2013 Federal Tax Return Transcript is required. Access and print your parent’s free IRS Tax Return Transcript (pdf) at

or call 1.800.908.9946 and follow the message prompts.

1. Will your parent’s income and/or resources be significantly less in 2014 than 2013?

circle one..... YES

2. If you answered “YES”, check the appropriate reason below and explain, giving the date of the change in your family situation:

Date of occurrence

a. Unemployment or change in employment; do not submit worksheet and documentation prior to August 1, 2014 unless parent

is currently re-employed and/or reduced income/resource information is known as of today’s date.

Documentation: Provide documentation of last day worked or copy of notification from employer stating change in employment/termination;

copy of final payroll statement; copy of most recent payroll statement from new employment; etc.

b. Divorce/separation -- provide only custodial parent income/resource information

Documentation: Attach copy of separation/divorce decree or a signed statement regarding the separation/divorce effective date and a copy of your

custodial parent’s 2013 W-2 forms. When completing Section 4 (below), provide only your custodial parent estimated 2014 income/resource information.

c. Death of parent -- provide only surviving parent income/resource information

Documentation: Attach signed letter noting date of death and copy of your surviving parent’s 2013 W-2 forms. When completing Section 4 (below), provide

only your surviving parent estimated 2014 income/resource information.

d. Loss of child support

Documentation: Attach a letter or court document stating termination of benefits, effective date. When completing Section 4 (below), indicate the reduced

2014 child support when reporting income/resources in Section 4, question 3.

e. One-time income (e.g., inheritance, moving expense allowance, non-recurring capital gain, Roth IRA, etc.)

Documentation: Identify the source of income/resource, the amount, and how the funds were spent or invested.

Provide 2013 Federal Tax Return Transcript; highlight/identify one-time income.

f. Disability of student or parent

g. Other

Documentation for (f), (g): signed statements documenting estimated 2014 income/resources. Include copy of most recent payroll statement, etc.

Provide adequate documentation to assist in a fair review of your family’s special circumstance.

Provide the following estimated 2014 income/resource information; if estimated 2014 income will be approximately the same as in 2013, indicate

“same”. Include all applicable custodial parent estimated 2014 taxable and untaxed income/resources. Do not leave blank.

Include actual amount earned/received January 1, 2014 to present date, plus estimated amount to be earned/received present date thru December 31, 2014.

Estimated Income

Estimated 2014 TAXABLE Income

Father/stepfather

Mother/stepmother

Wages, salaries, tips

$________________ $_________________

Net income/loss from business/farm

$________________ $_________________

Other taxable income (interest/dividend, capital gains, unemployment, alimony,

$________________ $_________________

taxable disability payments, severance pay, etc.)

Total estimated 2014 TAXABLE Income................................ $________________ $_________________

Estimated 2014 UNTAXED Income

- refer to FAFSA #94 a. thru i.

Child support

$________________ $_________________

Untaxed housing, food and other living allowances paid to military, clergy, others

$________________ $_________________

Untaxed portion of pensions, Veterans benefits, etc.

$________________ $_________________

…do NOT include Social Security or SSI

Tax deferred elective payments to 401K, 403B, untaxed elective contributions to

SEP/SIMPLE, IRA/Keogh

$________________ $_________________

Other untaxed income

$________________ $_________________

…do NOT include untaxed Social Security or SSI

Total estimated 2014 UNTAXED Income.................................... $________________ $_________________

CERTIFICATION: We certify that the information provided on this worksheet and any attached documentation is true and complete to the best of our knowledge.

The signatures below also allow the Professional Judgment information to be released to either the student or parent.

___________________________________________________________ ________________________________________________________________

Student signature

Date

Parent signature

Date

Student and parent signatures are required on this worksheet prior to review by the Augustana College Financial Aid Office.

verifypj_dep_1415.doc