2009-2010 SPECIAL CIRCUMSTANCES APPEAL FORM

Student’s Name____________________________________________ SS#______________________<= o:p>

Address_________________________________ Email______________________________________

City________________________ State_____ Zip_____________ Phone = (_____) ________________

NOTE: BEFOR= E YOU CAN BE CONSIDERED FOR AN APPEAL, YOU MUST HAVE ALREADY FILED YOUR 2009-2010 FREE APPLICATION FOR FEDERAL STUDENT AID (FAFSA).

The Higher Education Act and associated federal regulations give financial aid administrators the author= ity to make adjustments to an individual student’s federal aid application based on special circumstances within the household. The Calumet College of= St. Joseph Financial Aid Office will review and, when appropriate, make adjustm= ents to a student’s institutional, state and federal aid when a student, spouse, or parent have demonstrated a decrease in income for 2009. We reser= ve the right to delay review, until the end of the calendar year, any appeal w= here reasonable projections cannot be made.

STEP 1: AFFECTED PERSON(S)<= o:p>

Name(s) of person(s) whose income(s) have change= d: ________________________________

Indicate the above named person’s relation= ship to you (check all that apply):

____Self ____Spouse ____Father/Step ____Mother/Step ____Other (explain) _______________

STEP 2: CIRCUMSTANCE

Note: No action will be taken on this appe= al until we have received all required documentation.

(2008 taxes may be required if= not already provided through verification process.)

Date of Change

___Death of parent or spouse        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;                   =             ___/___/___<= /span>

Go to Step 3=

___Separation or ___Divorce        =                    =             &nb= sp;            =             &nb= sp;            =              =             ___/___/___<= /o:p>

Go to Step 3=

___Loss of job        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;                     =         ___/___/___

Required: Last paystub for job lost (& paystub for additional jobs held, if any) & Determination of Benefits Rights letter for unemployment benefits (& 2008 taxes if not already provided)

___Decrease in work hours of current position        =             &nb= sp;            =             &nb= sp;                     =         ___/___/___

Required: Last paystub of prev= ious hours & first paystub of current hours (& 2008 taxes if not already provided)

___Change of job resulting in reduction of income        =             &nb= sp;            =             &nb= sp;              =         ___/___/___

Required: Last paycheck of job before reduction and current paycheck (& 2008 taxes if not already provided) <= /p>
___Loss of unemployment benefits        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =           ___/___/___

Required: Paystub(s) before and after unemployment & Determination of Benefits Rights letter for unemployment benefits (& 2008 taxes if not already provided)=

___Loss of child support        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =                  =           ___/___/___

Required: Signed statement lis= ting monthly support and when it stopped

= ___Loss of other untaxable income (workman’s compensation, etc.)        =             &nb= sp;                   =          ___/___/___

Required: Letter from agency indicating amounts and ending date

___Medical/dental expenses not covered by insura= nce exceeding 11% of Income         =           ___/___/___

Protection Allowance (<= /span>minimum $17= 42 for dependent students, $770 independent students with no dependent children, $= 1949 independent students with dependent children) Required: Copies of IRS Schedule A or receipts of payment

___Significant change in student’s/parent’s income not listed above         =             &nb= sp;          =          ___/___/___

Required: Letter detailing circumstance (& any supporting documentation)

STEP 3: SEPARATION, DIVORCE= OR DEATH

If you or your parents have incurred a separatio= n, divorce or death after filing your 2009-2010 FAFSA, please complete = the following:

Number in Household in 2009-2010:_______* Number= in College in 2009-2010:_______*

*Include persons for whom you/= your custodial parent will provide more than half support for between July 1, 20= 09, and June 30, 2010, and persons who will attend college at least half-time (6 credit hours). For number in college, exclude parents.

STEP 4: ESTIMATED 2009 INCOME/BENEFITS

Using the chart below, enter = the total yearly income that _____you, _____your spouse, _____your parent(s) ex= pect to receive from January 1, 2009 through December 31, 2009. Complete ONLY for person whose income has changed. Use ONLY custodial parent in cases of divorce, separation and death. Use only Y= OUR income information if you are divorced, separated or widowed. If answer to = item is none, write -0-.

        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;         STUDENT/SPOUSE         =                  =     PARENTS

Wages, salaries and tips - 01/01/09 to today

$

(student) =

$

(father)<= o:p>

- today to 12/31/09

$

(student) =

$

(father) =

Wages, salaries and tips - 01/01/09 to today

$

(spouse) <= /p>

$

(mother)<= o:p>

- today to 12/31/09

$

(spouse) <= /p>

$

(mother) =

Other taxable income (interest, dividends, alimony, net business/farm income, capital gains, pensions, annuities, etc.)

$

$

&nb= sp;

Other untaxed income & benefits (untaxed interest, untaxed & taxed defe= rred pensions, workman’s compensation, IRA/Keough payments, etc.)

$

$

&nb= sp;

Child support paid (do not include for children claimed as part of household) <= o:p>

$

$

&nb= sp;

Will you receive any of the following benefits during 2009? ___Yes ___No

(If yes, please provide documentation and complete the following.)

___2009 estimated unemployment benefits $______________

___2009 estimated worker̵= 7;s compensation $______________

___2009 estimated child suppo= rt received (for all family members) $______________

Other Comments: _____________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= __

_____________________________= ________________________________________________________________=

_____________________________= ________________________________________________________________=

STEP 5: CERTIFICATION STATEMENT/SIGNATURES

I/We certify that all informa= tion and documentation that I/we have provided pertaining to this appeal is true= and complete.

Student______________________= ____ Date__________

Spouse_______________________= ___ Date__= _______

Parent’s signature is required only if parent’s information was provided above.<= /span>

Father_______________________= ____   Date__________

Mother_______________________= ____ Date_________

This appeal will be reviewed = by the Student Financial Aid Office. You will be notified in writing of the decision within 4 weeks of submitting this appeal. Required documentation must be attached to this appeal. Return completed form with attached documentation to the Financial Aid Office.

Financial Aid Office Phone: (= 219) 473-4296

Financial Aid Office Fax: (21= 9) 473-4340

Financial Aid Office Mail: 2400 New York Ave

        =             &nb= sp;            =             Whiting, IN 46394

Wages, salaries and tips - 01/01/09 to today	$	(student) =	$	(father)<= o:p>
- today to 12/31/09	$	(student) =	$	(father) =
Wages, salaries and tips - 01/01/09 to today	$	(spouse) <= /p>	$	(mother)<= o:p>
- today to 12/31/09	$	(spouse) <= /p>	$	(mother) =
Other taxable income (interest, dividends, alimony, net business/farm income, capital gains, pensions, annuities, etc.)	$		$	&nb= sp;
Other untaxed income & benefits (untaxed interest, untaxed & taxed defe= rred pensions, workman’s compensation, IRA/Keough payments, etc.)	$		$	&nb= sp;
Child support paid (do not include for children claimed as part of household) <= o:p>	$		$	&nb= sp;