Special Circumstance Consideration Independent Student ...

Special Circumstance Consideration

6500 Pacific Blvd SW, Albany, OR 97321

Independent Student

faoffice@linnbenton.edu

2021-2022

Office of Financial Aid & Veterans

Office: (541) 917-4850 | Fax: (541) 917-4864

______________________________ ___________________________ _____ ______________________________

Last Name

First Name

MI

Student ID Number

__________________________________________________________________ ______________________________

Mailing Address

Phone Number

An award offer for 2021-2022 must be made prior to completing this request. If your EFC is already 0, do not submit this form. Your financial aid offer cannot be increased.

The deadline for submitting a Special Circumstance Consideration is April 1, 2022.

This form does not guarantee an increase or change to your financial aid offer. Incomplete applications or delays in requests for additional information will result in a denied request.

Before completing this form, please visit our Special Circumstance Guidelines page for information:

All applicants must complete Section A & C. Please complete Section B if requested in Section A.

Section A: Identifying Special Circumstance and Required Documentation for Review

1. Medical/Dental paid in 2020 ? Must not be covered by insurance ? Must not be an outstanding balance

1. All signed 2020 Federal 1040 Form and Schedules 1-3, if used 2. All 2020 W-2s (or other income from work) 3. Copies of receipts paid in 2020 and a summary of amounts

paid by you or your parent(s) in 2020

2. Child support received ? Benefits have reduced or stopped as reported on 2021-2022 FAFSA

1. Court or Child Service Agency documentation stating benefit end date and amount received in 2021 for each child

3. Unemployment benefits ? Benefits have terminated; or ? Received benefits within the last 90 days and are still unemployed

Submit documentation per option A or B based on your situation.

A. If your benefits have been terminated and were reported on your 2019 or 2020 Federal 1040 Form 1. Copy of signed 2019 and/or 2020 Federal 1040 Form 2. Notice from agency reflecting the date benefits ended with the total amount received, and 3. Signed explanation of your situation

B. If you received benefits within the last 90 days 1. Copy of weekly benefits summary indicating amount and date funds were received within the last 90 days 2. Signed statement indicating you are still unemployed

4. Divorced/separated*

1. Court document or notarized statement of divorce/separation status and dates Month/Year divorced/separated: _____________

2. Signed copy of student/ex-spouse's 2019 Federal 1040 Form 3. Student/ex-spouse's 2019 W-2s (or other income from work)

5. Spouse on FAFSA deceased*

Will you receive survivor benefits?

No

Yes

1. Copy of death certificate 2. Signed copy of student/spouse's 2019 Federal 1040 Form 3. Student/spouse's 2019 W-2s (or other income from work) 4. Survivor benefits statement (if applicable)

LBCC Comprehensive Statement of Nondiscrimination

LBCC prohibits unlawful discrimination based on race, color, religion, ethnicity, use of native language, national origin, sex, sexual orientation, gender, gender identity,

marital status, disability, veteran status, age, or any other status protected under applicable federal, state, or local laws. For further information, see Board Policy 1015.

Title II, IX, & Section 504: Scott Rolen, CC-108, (541) 917-4425; Jill Childress, jill.childress@linnbenton.edu, LBCC, Albany, Oregon.

To report: linnbenton-advocate.public_report

Rev. 02/01/2021

6. Loss or Change in employment

? Income loss of 8 weeks or more

Wage earner's name:

________________________________

Date employment ceased: ___________

Has/will wage earner return to work in

2021?

No

Yes

7. Your/your spouse's 2020 Adjusted

Gross Income (AGI) is significantly

less than their 2019 AGI

1. Official letter from employer stating loss/change in job status 2. All signed 2020 Federal 1040 Form and Schedules 1-3, if used 3. All 2020 W-2s (or other income from work) 4. Complete Section B: 2021 Estimated Income (below)

(If it is after Nov. 1, 2021 your signed 2021 Federal 1040 Form, Schedules 1-3 if any, and 2021 W-2s will be required)

1. All signed 2020 Federal 1040 Form and Schedules 1-3, if used 2. All 2020 W-2s (or other income from work) 3. Signed explanation of why AGI is lower in 2020

8. Other

? Any circumstance not listed above that will cause you and/or your spouses 2020 or 2021 taxed or untaxed income to be significantly less than the 2019 income reported on the 2021-2022 FAFSA

1. A signed statement explaining change in circumstance, including why funds are not available for educational expenses

2. All signed 2020 Federal 1040 Form and Schedules 1-3, if used 3. All 2020 W-2s (or other income from work) 4. If applicable, third-party letters to support your situation 5. Complete Section B: 2021 Estimated Income (below)

(If it is after Nov. 1, 2021 your signed 2021 Federal 1040 Form, Schedules 1-3 if any, and 2021 W-2s will be required)

* Your 2021-22 FAFSA may be selected for verification due to the removal of a person from the household size. You will be notified of any Outstanding Requirements in Webrunner if this occurs.

Section B: 2021 Estimated Gross Earned Income, Untaxed Income, and Other Benefits

Submit the documentation used (e.g., your most recent year-to-date pay stub, etc.) to estimate your 2021 gross income, along with a signed statement of how you determined and calculated (e.g., rate of pay x hours worked in a pay period) your 2021 calendar year (Jan. 1st to Dec. 31st) estimated gross income below.

2021 Estimated Income/Resources 2021 Estimated or actual gross wages earned/anticipated

Student

$

Spouse

$

Total

$

2021 Unemployment benefits

$

$

$

2021 Disability benefits. Are these taxable? YES

NO

$

$

$

2021 Child support received/expected in 2021

$

$

$

Other untaxed 2021 income Source (explain): _____________________________________

$

$

$

Other taxable 2021 income (expected interest, dividends, alimony,

capital gains, etc.).

$

$

$

Source (explain): _____________________________________

Total 2021 estimated taxed and untaxed income $

$

$

Section C: Certification and Signatures

By signing below, I acknowledge that I have attached all supporting documentation and that all information submitted is accurate and true to the best of my knowledge. Information provided may be discussed with the student as necessary. I have read the Special Circumstance Guidelines and understand that submitting this form does not guarantee that my request will be granted.

Student's Ink-Signature: _____________________________________________ Date: ________________

Spouse's Ink-Signature: _____________________________________________ Date: ________________ (Optional)

SUBMIT COMPLETED FORMS & DOCUMENTATION to: faoffice@linnbenton.edu

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