▲ ▲ Uni versi ty of Illi nois S pringfiel d – Office of Financial Assistance One Universtiy Plaza, MS UHB 1015 ­­ Springfield, Illinois 62703­5407 ­­ Phone: (217) 206­6724 2012­2013 Change of Financial Situation ­ Dependent
Section A – Student Information (Please print clearly) Last Name First Name Street Address What you should do: M.I. Email City State Zip Code If the information you have reported on your 2012­13 Free Application for Federal Student Aid (FAFSA) does not accurately reflect your current situation, you may be eligible to have your financial aid file re­evaluated. In order to have your file re­evaluated, you must submit ALL of the following information: Dependent Student (per the FAFSA) ___ Complete and submit this entire form per the instructions with appropriate documentation. ___ Submit 8 ½ x 11 legible copies of all 2011 W­2 forms/benefit statements and signed federal income tax returns for you and your parent(s). ___ Submit a 2012­13 Dependent Verification Worksheet. If this form is not completed and the proper documentation is not submitted, your file will not be reviewed. Keep in mind that as a result of reviewing the additional documentation submitted there may be an increase or decrease in your financial aid eligibility. If your financial aid eligibility changes, you will be notified accordingly. Section B – Indicate Reason(s) for Change of Financial Situation ____ A. Unusual medical or dental expenses paid not covered by insurance and not claimed as a deduction on your Federal income tax return during the 2011 tax year (January 1, 2011 ­ December 31, 2011). As a general rule, these expenses should be at least 15% of your Adjusted Gross Income before submitting documentation. Documentation required: proof of payment such as canceled checks or receipts (please total amounts). ____ B. If you or your parent(s) worked full­time in 2011 but lost his/her job and remained unemployed for at least 10 weeks during 2012 or if you or your parent(s) were employed full­time in 2011, but now are only employed part­time in 2012. As a general rule, the projected 2012 Adjusted Gross Income (AGI) should be at least 20% less than the actual 2011 AGI before submitting documentation. Documentation required: a statement from previous employer on company letter head indicating the first and last day of employment or in the case of reduced hours, a similar letter stating your hours have been reduced. ____ C. If you or your parent(s) worked full­time in 2011 but have been unable to pursue normal income producing activities for at least 10 weeks during 2012 due to a disability, etc. As a general rule, the projected 2012 Adjusted Gross Income (AGI) should be at least 20% less than the actual 2011 AGI before submitting documentation. Documentation required: a letter from a physician regarding the disability or a letter from another source documenting reason. ____ D. If you or your parent(s) received untaxed income in 2011 and had a complete loss of one of the benefits for at least 10 weeks in 2012. This would include Child Support, Disability Benefits, and Veterans Benefits. As a general rule, the projected 2012 total income should be at least 20% less than the actual 2011 total income before submitting documentation. Documentation required: a written statement from the appropriate agency showing the date the benefit was lost. ____ E. If you or your parent(s) have become separated or divorced after submission of your original FAFSA. Please list the date of separation or divorce: _____/_____/_____. Documentation required: copy of the temporary separation order or divorce decree from the court or documentation such as lease, mortgage, etc. which shows two separate households. ____ F. If your parent(s), whose 2011 income was reported on the FAFSA, has died after submission of the FAFSA application. Documentation required: Death Certificate. ENTER YOUR 9­DIGIT UIN. 1213 ▲ CFSD­O B 6 6 6 6 6 6 6 6 6i '
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▲ Section 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. If you have requested a parent’s special circumstance, complete all lines in the Mother/Stepmother and Father/Stepfather columns. If you have requested a student’s special circumstance, complete all lines in the Student column. If you have requested both a parent’s and student’s special circumstance, complete all lines in all columns. In either case, both parent and student must sign this form. 1. 2. Answer each line with an amount or “zero” if it does not apply (the form is incomplete unless each line is answered). 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 (do not include your unemployment income as wages) Student Mother Father 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: Untaxed Disability Income Provide monthly statement 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/we certify that the information provided on this form and any attachments are true and correct. Additionally it is understood that I/we must notify the Office of Financial Assistance if the situation outlined in this request changes. Student Signature Date ENTER YOUR UIN Parent’s Signature (if dependent) 6 6 6 6 6 6 6 6 6i '
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