2014-2015 Financial Aid Income Change Appeal Page 2
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42014-2015 INCOME CHANGE
APPEAL FORM
Name
WNCC Student ID#
(please print)
Mailing Address, City, State, Zip
DOB or Last 4 SSN digits
Phone
E-mail
In addition to completing this form and providing all situation-specific supporting documentation, all appeals must
include the following documentation:
A typed (or neatly hand-written), signed statement explaining your family’s special circumstances
Signed copy of your 2013 Federal Income Tax Return and W-2 forms
Signed copy of your spouse’s 2013 Federal Income Tax Return (if married) and W-2 forms
Signed copy of your parents’ 2013 Federal Income Tax Return (if dependent) and W-2 forms
A copy of the most recent pay stub from each employer
Verification of all untaxed income received in 2013
Complete the Estimated Income Worksheet on page 4
Appeals submitted after 12/31/14 must include signed copies of 2014 Federal Income Tax Returns and W-2
forms
*Please note that omitting required documentation may cause delays in your appeal’s review or your appeal may be
denied.
Section A: Reason for Income Change Appeal (check all that apply)
A. Unemployment or reduction of hours or wages
Student, spouse or parent who worked in 2013 is now unemployed or has had work hours and/or wage rate
reduced.
Required documentation:
o
Copy of last pay stub(s) from previous employer(s)
o
Copy of letter from employer on letterhead verifying the release from employment or reduction in
hours/wages, the date the change became effective and the duration of the reduction if temporary
o
Notice of eligibility or denial for unemployment benefits
o
Copy of disability benefit statement if applicable
B. Medical or dental expenses
You, your spouse or parent made payments for expenses not covered by insurance. Medical expenses for
which you received no insurance or other reimbursement must exceed 11% of the family’s taxable income
in order to be considered for appeal.
Required documentation:
o
Submit copies of receipts or billing statements showing amounts for which you received no insurance or
other reimbursement, as well as documentation of payment.
o
Total medical expenses for which you received no insurance or other reimbursement(s):
$__________________.
Page 2 of 4
K:\FinancialAid\FA FORMS\2014-2015\14-15 Appeals\Income Change Appeal form 2014-15.doc
(Revised 02/15/14 color yellow)
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