Request For Consideration Of Special Circumstances

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OFFICE OF FINANCIAL AID
300 Seward Street
PO Box 248
Ripon, WI 54971
920-748-8101
REQUEST FOR CONSIDERATION OF SPECIAL CIRCUMSTANCES, 2015-2016
Student Name: _____________________________
Social Security Number: __________________________
Daytime Phone Number: _____________________ Email: __________________________________________
Do not submit this form unless you have already filed a 2015-16 Free Application for
Federal Student Aid (FAFSA) and received an award letter from the Ripon College
Office of Financial Aid. If you submit this form you must also complete the verification
process (please see verification worksheet for details).
Your financial need is based on the information you provide on your Free Application for Federal Student Aid (FAFSA).
If your income has recently decreased or you have special circumstances that you were not able to account for on your
FAFSA, you may utilize this form to provide our office with information regarding your situation.
You must attach a separate page (printed or typed) to describe major expenses and reasons for any significant changes.
Details and examples are given for each question. In your explanations, be sure to include applicable dates, dollar
amounts, reason(s) for significant changes from year to year, etc. When reporting future expenses or income, we simply
ask that you make your best estimate. We will let you know if any other documentation is required.
PLEASE INDICATE BELOW THE SPECIAL CIRCUMSTANCE(S) YOU WOULD LIKE OUR OFFICE TO CONSIDER:
____ 1. Anticipated Income, January – December 2015
Anticipated Income, Parents’ and Students’: Complete this section only if: (1) your parent anticipates a change of
at least 10% in total income; (2) you (the student) anticipate a change of at least $1,000.
Parent 1 Income from work: $___________________ Parent 2 Income from work: $______________________
Student’s Income from work: $__________________ Spouse’s Income from work: $______________________
Documentation Required:
Copy of most recent pay stub
Notice of benefits determination
Copy of prior year Federal Tax Return & W-2s
Separate page (printed or typed) explaining the reason(s) for any significant change, make sure to include
the dates on which changes occurred.
_____2. 2014 Healthcare Expenses: Provide estimated figures for the entire year. $_________________________
A. Include only those expenses you are allowed to report as “Itemized Deductions” (1040 Schedule A, Line 1)
even if you do not have enough to itemize. Examples: hospital care, lab fees, co-payments, deductibles,
prescriptions, braces, etc.
B. Important: If you are self-employed and claim the cost of health insurance on line 29 of the federal tax
return (1040), you may not include that cost on this application.
C. Do not include any expense that is or will be: reimbursed by insurance, paid with pre-tax dollars (referred to
as a cafeteria plan, flexible spending account, health savings account, etc.), paid by your employer or billed in
one year but paid in another.
a.
Example: Suppose that the total of all bills received in 2014 for medical procedures, office visits,
dental exams and prescriptions was $9,000. Insurance paid $4,000, and $1,000 came from your
parent’s pre-tax flexible spending account (or similar). Only the remaining $4,000 “out of pocket” can
be considered for financial aid purposes.

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