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You have indicated a change in available income for the current academic year. If you believe the Expected Family Contribution (EFC) calculated on your Student Aid Report does not accurately represent your family’s ability to contribute toward your educational expenses, you may request the Financial Aid/VA Office to exercise Professional Judgment and adjust data elements accordingly.
The decision reached by the Financial Aid/VA Office is final and cannot be appealed to the U. S. Department of Education.
This form must be returned to the Financial Aid Office/VA with all required documentation.
Student Name: _________________________________________ SSN:___________________________________
Address: ______________________________________________ Telephone:______________________________
______________________________________________ Date: __________________________________
PERSONAL STATEMENT:
Please print or type below an explanation as to your reasons for requesting special consideration of your financial situation. You must provide specific details as to how your situation is not accurately represented on your Student Aid Report.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Will your income (including parent or spouse) be less in 2003 than in 2002 (as reported on your tax returns) for any of the reasons listed? ______ Yes _____ No
If yes, check the appropriate reason and give the date of the change in your situation:
q 1. Unemployment or lack of full-time employment for at least three months in
the current year. (Please attach a copy of the letter of termination.) Date: __________
of explanation.) Date: ___________
q 3. Disability. (Please attach certification of disability from certified
professional.) Date: __________
q 4. Loss of unemployment benefits. Date: ___________
(Please attach a copy of your unemployment benefit statement.)
q 5. Loss of untaxed income received last year which is no longer available.
(State source and amount: ____________________ $__________.) How were funds spent or invested?
___________________________________________________________________________________
You or your spouse and/or parent(s) incurred expenses including:
q 1. Unusual medical/dental expenses not paid by insurance.
What were your base year medical/dental expenses not paid by insurance? $___________
(Please provide a receipt or statement indicating all expenses you paid and a copy of your tax return
listing itemized deductions.)
How much did you pay for medical/dental insurance for the base year? (Do not include employer’s
contribution.) $__________
(Please provide a copy of your wage statement or bill indicating your cost for medical/dental insurance.)
In the estimated year, will your non-reimbursed medical/dental expenses be: (Please check one.)
___ lower ___the same __ higher
Explain the reason.
__________________________________________________________________________________
__________________________________________________________________________________
From what source will you finance these expenses?
__________________________________________________________________________________
Data Verification: Please provide a copy of your income tax return (itemized medical and dental deductions); receipts of medical and dental payments.
q 2. Elementary or secondary education paid for children at private school and dependent care
expenses.
Please answer the following:
Do you pay for elementary or secondary education expenses or dependent care expenses? ___Yes ___No
If “Yes,” provide the following information for each family member receiving such support:
Name of supported family member: _______________________________________________
Age of family member: __________ Relationship to student: ___________________________
Child care expense: $___________ Elementary/secondary education expense: $___________
Adult dependent care expense: $_________ Total annual expense for base year: $_________
In the estimated year, will these expenses be: (Please check one.)
___ lower ___ the same ___ higher
Explain the reason.
_____________________________________________________________________________________
_____________________________________________________________________________________
From what sources will you finance these expenses?___________________________________________
Data Verification: Please provide a copy of your current income tax return listing dependents; receipts for
tuition payments; receipts for adult dependent care expenses; receipts for childcare expenses;
signed itemized statement of expenses.
q 3. Support to Extended Family
To address on a case-by-case basis, families who provide financial support to relatives who are unable to
support themselves adequately but who do not qualify as family members, please answer the following
questions:
Do you contribute financial support to a relative(s) not counted as a member(s) of your
household? ____ Yes ____ No
If “Yes,” provide the following information for each relative:
Name of the supported relative: ________________________________________________________
Age: __________ Relationship to student: ________________ Amount paid by you: $___________
Amount paid by other sources: $____________ Reason for support: __________________________
__________________________________________________________________________________
__________________________________________________________________________________
Support began (month,year): _______________ Support ends (month, year):________________
In the estimated year, will these expenses be:(Please check one.)
___ lower ___ the same ___ higher
Explain the reason.
_________________________________________________________________________________
_________________________________________________________________________________
From what sources will you finance this support? __________________________________________
Data verification: Please provide receipts and billing statements.
q 4. You or your parents were separated or divorced after the needs analysis
was submitted. Date: ____________
(Attach a copy of separation or divorce papers.)
q 5. A parent or spouse died after the needs analysis was submitted. Date: ____________
(Attach a copy of death certificate.)
q 6. Other Circumstances. To address on a case-by-case basis families with unusual circumstances, such as
failed business; legal fees for divorce, adoption, etc.; education loans or parents or spouses; or one or more
parent attending college.
Please explain “other” circumstance. ________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
From what sources will you finance these expenses:_____________________________________________
Data verification: Please provide the necessary documentation requested by the Financial Aid/VA Office.
PART II: Estimated Income
If you are divorced or separated, include only your income information; if your parent is divorced or separated, include your custodial parent’s income information. If the loss of income is due to the death or your spouse include only your income; if the loss of income is due to the death of a parent, include your surviving parent’s income information.
PART III: Student, Spouse or Parent Certification:
All of the information on this form is true to the best of my/our knowledge. Also, I/we have provided documentation to verify the information provided.
Student’s Signature:_____________________________________________ Date:_____________________________
Spouse’s Signature: ____________________________________________ Date:_____________________________
Parent’s Signature: _____________________________________________ Date:_____________________________
PART IV: Certification for Corrections
If your professional judgment is approved and you would like for us to indicate your estimated earnings for this year, please read and sign the following:
I agree to have my corrections sent electronically by Central Piedmont Community College’s Financial Aid/VA Office.
I certify that all of the information provided and corrected on my Student Aid Report is true and complete to the best of my knowledge. If I am asked, I agree to give proof that any information is correct. This proof might include a copy of my U.S. Tax Return filed by my family or me. I understand that if I purposely give false or misleading information on my Student Aid Report, I may be subject to a $20,000 fine, a prison sentence, or both.
Student’s Signature:_____________________________________________ Date:_____________________________
Spouse’s Signature: ____________________________________________ Date:_____________________________
Parent’s Signature: _____________________________________________ Date:_____________________________
(If you are a dependent student, a parent signature is also required.)
Reason: _____________________________________________________________________________________
_____________________________________________________________________________________________
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Current Income |
Current Taxes Paid |
Adjusted Income for PJ |
Adjusted Taxes Paid for PJ (per EDExpress) |
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Parental Information
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$ |
$ |
$ |
$ |
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Student Information
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$ |
$ |
$ |
$ |
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Spouse Information
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$ |
$ |
$ |
$ |
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