Page 1 Special Circumstance Form 2020-21 Student ID# Name Phone # NDSU Email Have you submitted a Special Circumstance Form to NDSU in any previous year? If you are completing this form you are requesting that financial aid award be re-evaluated because of a special circumstance which impacts your/your parent(s) ability to contribute toward your 2020-21 educational expenses. The submission of this form does not guarantee a favorable change in your financial aid award. All students who are eligible for a special circumstance revision will be required to complete verification. Once verification is complete your special circumstance revision will be completed. This may take up to 4 weeks. The results of your special circumstance revision will be sent to your NDSU email address. Submit this completed and signed form and all supporting documentation listed for your specific special circumstance category to: NDSU One Stop NDSU Dept. 2836 PO Box 6050 Fargo, ND 58108-6050 Fax: (701) 231-8297 Scan and Email to [email protected]Drop off location: 176 Memorial Union (NDSU One Stop) I certify the information on this form is true and accurate to the best of my knowledge. I understand that purposely giving false or misleading information will result in denial of my request and I may be subject to, fines, penalties, and/or reduction or immediate repayment of aid, and referral to Student Affairs for a code of conduct violation. I understand that the information provided on this form may affect my/my student’s financial aid eligibility/award. Student Signature ______________________________________________________ Date ______________________ Note: Unsigned documents will be returned. This form must be signed with a physical signature. Typed names or electronic signatures are not acceptable. Parent Signature (if parental information is provided) _________________________________ Date ______________________ Note: Unsigned documents will be returned. This form must be signed with a physical signature. Typed names or electronic signatures are not acceptable. HOUSEHOLD INFORMATION Include all members of your household in the chart below. Dependent Students - include yourself, your parent(s), and any dependents for which your parent(s) provide more than half of their support. Independent Students - include yourself, your spouse, and your dependent children. Name Age Relationship to Student College/University Attending in 2020-21 Student NDSU If more space is required, attach a separate page.
Transcript
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Special Circumstance Form 2020-21
Student ID#
Name
Phone #
NDSU Email
Have you submitted a Special Circumstance Form to NDSU in any previous year?
If you are completing this form you are requesting that financial aid award be re-evaluated because of a special
circumstance which impacts your/your parent(s) ability to contribute toward your 2020-21 educational expenses.
The submission of this form does not guarantee a favorable change in your financial aid award.
All students who are eligible for a special circumstance revision will be required to complete verification.
Once verification is complete your special circumstance revision will be completed. This may take up to 4 weeks.
The results of your special circumstance revision will be sent to your NDSU email address.
Submit this completed and signed form and all supporting documentation listed for your specific special circumstance
Drop off location: 176 Memorial Union (NDSU One Stop)
I certify the information on this form is true and accurate to the best of my knowledge. I understand that purposely giving false or misleading information will result in denial of my request and I may be subject to, fines, penalties, and/or
reduction or immediate repayment of aid, and referral to Student Affairs for a code of conduct violation. I understand that
the information provided on this form may affect my/my student’s financial aid eligibility/award.
Student Signature ______________________________________________________ Date ______________________ Note: Unsigned documents will be returned. This form must be signed with a physical signature. Typed names or electronic signatures are not acceptable.
Parent Signature (if parental information is provided) _________________________________ Date ______________________ Note: Unsigned documents will be returned. This form must be signed with a physical signature. Typed names or electronic signatures are not acceptable.
HOUSEHOLD INFORMATION Include all members of your household in the chart below.
Dependent Students - include yourself, your parent(s), and any dependents for which your parent(s) provide more than half of their
support. Independent Students - include yourself, your spouse, and your dependent children.
Name Age Relationship to Student College/University Attending in 2020-21Student NDSU
If more space is required, attach a separate page.
INSTRUCTIONS - Identify your special circumstance(s) by marking (X) each category that pertains to you. Answer all
questions in selected categories and attach any additional information required.
NOTE: If you have requested review in more than one category, be sure to include the required documentation for each
category. Forms with incomplete documentation will not be processed.
LOSS OR REDUCTION OF INCOME • Select this category if you/your parents' 2020 projected income (January 2020 - December, 2020) will be less than the
2018 income reported on the FAFSA. Must wait 10 weeks after reduction of income before submitting this form and reduction must occur before November 1, 2020 for consideration. Complete ALL columns in the chart below.
• If the loss of income is for one parent, but their combined 2020 earnings will exceed their 2018 earnings, do not complete this section.
Complete the section below and submit the following required documentation:
1. A copy of the most recent pay stub showing 2020 year-to-date earnings for the person with the loss/reduction of income
2. A copy of the termination, lay-off notice or final pay stub, if you have one.
3. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted the ability to contribute toward your 2020-21 educational expenses. If requesting an adjustment for more than one category, only
one statement is needed.
LOSS/REDUCTION OF INCOME & REPORTING 2020 PROJECTED INCOME Student
Father/
Step-Father
Mother/
Step-Mother
Spouse of
Student
Did this family member have a loss/reduction of income? If no, skip to lower section.
Date of Income Loss/ReductionReason for Income Loss/Reductioni.e. coronavirus outbreak, terminated, seasonal lay-off, attending college, etc.
Complete the section below to project 2020 calendar year income (January 2020 – December 2020) for all
columns. Estimate the figures to the best of your ability. Don't leave anything blank; if the amount is $0, enter $0.
2020 GROSS (not net) earnings from work $ $ $ $
2020 Unemployment Benefits $ $ $ $
2020 Child Support $ $ $ $
Other (Specify source of income) ___________________________ i.e. worker’s compensation, private disability, spousal support, etc. $ $ $ $
SEPARATION OR DIVORCE OF PARENTS • Select this category if your parent(s) were married when you completed the FAFSA but are now divorced or are
separated with the intent to divorce. Complete the chart below.
• Students – Do NOT use this form to update your marital status. If you have a marital status update, please call Mary at701-231-8398 for assistance.
Complete the chart below and submit the following required documentation:
1. Copy of parents’ divorce judgement and decree or a letter from an attorney stating legal proceedings have begun.
2. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted your/your
parent(s) ability to contribute toward your 2020-21 educational expenses. If requesting an adjustment for more than
one category, only one statement is needed.
SEPARATION OR DIVORCE OF PARENTS
Date of Parents’ Separation/Divorce
Which parent provides the majority of your support?
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Student ID #
Name
LOSS OR REDUCTION OF BENEFITS (CHILD SUPPORT, UNEMPLOYMENT, SPOUSAL SUPPORT, PRIVATE DISABILITY)
• Select this category if you, your spouse or parent(s) received benefits in 2018 that will not be available in 2020. Complete the chart below.
• Do NOT include the following: Social Security Benefits (SSI or SSDI), medical or other “benefits” received with an employment package.
Complete the section below and submit the following required documentation:
1. Letter or documentation from court or other agency verifying the date of the reduction or termination of the benefit.
2. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted the ability to
contribute toward your 2020-21 educational expenses. If requesting an adjustment for more than one category, only one
statement is needed.
BENEFIT LOSS
Name of Household Member Name of Household Member
Relationship to Student
Type of Benefit (i.e. child support, unemployment, spousal support, etc.)
Date of Benefit Loss/Reduction
Reason for Benefit Loss/Reduction i.e. benefit terminated, child turned 18, court ordered change, etc.
2018 Total Amount of Benefit Received (Jan. – Dec. 2018) $ $
2020 Total Amount of Benefit Expected (Jan. – Dec. 2020) $ $
OUT-OF-POCKET PAYMENTS FOR 2019 MEDICAL/DENTAL/VISION EXPENSES and HEALTH INSURANCE PREMIUMS • Select this category if you, your spouse or parent(s) paid 2019 medical/dental/vision expenses or health
insurance premiums in excess of 7.5% of your 2018 Adjusted Gross Income. Complete the chart below.
• Bills will only be considered if they were incurred and paid in 2019 and were NOT covered by insurance.
• Adjustments will not be made for medical expenses until after January 1, 2020.
Complete the section below and submit the following required documentation:
1. Proof of payment (see examples of acceptable documentation below)
a. If you/your parent(s) itemized deductions on the 2019 tax return, a copy of Schedule A must be submitted with this form. If you will be itemizing your taxes, submit this form after the 2019 taxes are filed.
b. If you/your parent(s) paid health insurance premiums in 2019 that were NOT included on Line 1 of Schedule A or did not itemize your taxes, submit a copy of the 2019 premium statement, a letter from the insurance company stating the total amount paid in 2019, or your final 2019 pay stub showing the total premium amount that was deducted from the paycheck.
c. If you/your parent(s) did NOT itemize and took the standard deduction, submit a letter from each provider indicating the total amount paid out-of-pocket 2019 medical/dental/vision expenses.
2. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted the ability to
contribute toward your 2020-21 educational expenses. If requesting an adjustment for more than one category, only one
statement is needed.
MEDICAL/DENTAL/VISION EXPENSES OR PREMIUMS
2019 Total Expenses Paid (not covered or reimbursed by insurance) $
2019 Total Health Insurance Premiums Paid $
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Student ID #
Name
UNUSUAL DEBT OR EXPENSE • Select this category if you, your spouse or parent(s) had an unusual debt or expense in 2019 that was unavoidable and
will negatively impact the ability to pay for educational expenses. Complete the chart below.
• Only paid expenses will be considered.
• Expenses that may be considered include: dual housing costs necessitated by economic conditions, funeral expenses not covered by life insurance, natural disaster expenses not covered by insurance, FEMA or other agency, special
travel/lodging for medical reasons, etc.
• Expenses that cannot be considered include: vacations, weddings, standard living expenses, home renovations, credit card debt, auto loans/insurance, auto repairs, expenses related to self-employment, etc.
Complete the section below and submit the following required documentation: 1. Description of debt or expense
2. For Natural Disaster – Documentation of completion of repair and final total cost. A letter from FEMA and insurance
agency indicating amount they will cover. Proof of payment to cover remaining cost of repair.
3. For Dual Housing Costs – Copies of lease showing amount paid for rent and names of renters and heat/electric/water
bill. Lease or mortgage statement from primary residence.
4. For Other Unavoidable Expenses – Copies of bills, receipts or other documentation that verifies the debt or expense.
5. For Elementary/Secondary Private School Tuition - Copy of the 2019 tuition bill(s) from the private school(s) attended
or letter from school with the total cost. Documentation from a physician, counselor, or school official detailing the
specific needs of the student attending private school and confirming that it is not possible for the student to receive
needed services or accommodations in a public school setting.
You must also: Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted your/your parent(s) ability to contribute toward your 2020-21 educational expenses. If requesting an adjustment for more thanone category, only one statement is needed.
UNUSUAL DEBT OR EXPENSE
Name of Household Member Name of Household Member
Relationship to Student
Type of Debt/Expense (i.e. funeral expense, dual housing, etc.)
Amount of Debt/Expense $ $
DEATH OF PARENT OR SPOUSE • Select this category if your parent(s) or spouse passed away after your FAFSA was filed. Complete the chart below.
• If their funeral expenses were not covered by life insurance, you may also wish to complete the Unusual Debt or
Expense category above.
Complete the section below and submit the following required documentation:
1. Copy of death certificate, obituary or memorial program.
2. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted your/yourparent(s) ability to contribute toward your 2020-21 educational expenses. If requesting an adjustment for more thanone category, only one statement is needed.
DEATH OF PARENT/SPOUSE
Name of Deceased
Relationship to Student
Date of Death
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Student ID #
Name
ROTH IRA Select this category if you/your parent(s) or spouse converted a regular IRA to a Roth IRA by transferring funds and the
amount converted was reported as taxable income on you/your parent(s) 2018 federal income tax return.
Submit the following required documentation:
1. Copy of Form 8606 (Nondeductible IRA) for the 2018 tax year for the person with the Roth IRA.
ADDITIONAL INCOME IN 2018 USED TO PAY OFF DEBTSelect this category if you, your parent(s) had additional income in 2018 that was used to pay off debt, to avoid bankruptcy, foreclosure, referral to collections, or other extreme financial hardship (including payment of standard living costs following a
loss of income), and that income was reported as a capital gain on your 2018 taxes. Complete the chart below.
Complete the section below and submit the following required documentation:
1. Written statement outlining how funds were spent (bills paid and amounts).
2. Documents from lenders/creditors showing the amount of debt that was paid and the date it was paid.
a. If the outstanding debt was paid prior to referral to collections, submit a letter from the agency stating the
account/bill was past due.
b. If assets were liquidated to pay standard household expenses due to lost or reduced income include a list of
specific costs covered and documentation of the reason for the lost or reduced income.
3. Provide a detailed written explanation of you/your parent(s) special circumstance and how it has impacted your/your
parent(s) ability to contribute toward your 2020-21 educational expenses. If requesting an adjustment for more than
