Change Of Financial Situation Independent Page 2
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2Section C –
Anticipated Income for 2012 (Complete only if you checked B, C, D, E or F above)
EXPECTED TOTAL INCOME AND BENEFITS TABLE
Please include all of your households projected income for 2012
1. Answer each line with an amount or “zero” if it does not apply (the form is incomplete unless each line is answered).
2. Remember to submit the requested documentation, pay statements, etc. to support the special circumstance request.
Documentation should show gross amounts.
EXPECTED TOTAL INCOME AND BENEFITS
January 1, 2012 through December 31, 2012
TAXABLE INCOME FROM WAGES
Student
Spouse
(do not include your unemployment income as wages)
Document gross wages
earned through today’s date:
Provide most recent pay statement
Estimated anticipated wages from today’s date through December 31, 2012:
OTHER TAXABLE INCOME:
Unemployment Income to date and anticipated in 2012:
Provide monthly statement
Severance, Paid Time Off or Vacation Pay Out if not included in gross wages
Social Security Income:
Provide monthly statement
Taxable Disability Income:
Provide monthly statement
Taxable Pension:
Provide monthly statement
Interest/Dividend Income: You should anticipate any type of asset income you are
required to report on your 2012 federal tax return.
Business income, Rents, royalties, and/or annuities
Maintenance/support from spouse in 2012 (in cases of separation or divorce)
Taxable income from 401k disbursements or other existing assets:
Include year to date gross disbursements and anticipated disbursements
Other taxable incomes: List the source
TYPES OF UNTAXED INCOME
Housing allowance for military or clergy
Contract or LES Statement
Workers Compensation:
Provide monthly statement
Untaxed Disability Income
Provide monthly statement
Child Support Received for all members of your household
Untaxed Pension
Provide monthly statement
Other Untaxed Income: List the source
Section D –
Statement of Certification
IMPORTANT:
Return this original form to the Office of Financial Assistance. All documentation submitted with this form must:
1. Have legible copies made on 8 ½ x 11 paper.
2. Have UIN clearly printed within the boxes on this form.
3. Have all appropriate signatures.
*** If this form is not complete and the proper documentation is not submitted, your file will not be reviewed.***
I certify that the information provided on this form and any attachments are true and correct. Additionally it is understood that I must notify the Office of
Financial Assistance if the situation outlined in this request changes.
___________________________________
Student Signature Date
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ENTER YOUR UIN
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