York County Community College
FINANCIAL AID OFFICE
EXPLANATION OF SPECIAL CIRCUMSTANCES
20__ - 2__

Student Name___________________________ SS Number _____________________________

You indicated there are special circumstances to be considered when your aid eligibility is determined. Please provide more detailed information about these circumstances by completing this form. If there is other information you want to have considered, please explain on a separate sheet and attach it to this form.

Check the situations that apply to you, complete the estimated income section on the back, and sign the for

_______ Unemployment or change of employment situation
Who does this apply to?   ___Self  ___Spouse  ___Mother  ___Father
Date change occurred _____________
What caused the change? __________________________________________________
 
_______ Separation or Divorce
Date of separation or divorce_____________
How will assets be divided (do not include home)? _______________________________
What are custody arrangements for children (if any)? ______________________________
Who will pay child support, and what is the amount? ______________________________
 
_______ Loss/Reduction of Income or Benefits
  Who does this apply to?  ___self  ___spouse  ___mother  ___father
  Type of income or benefit __________________________________________________
  Amount of income _______________
  Date on which the income/benefit was ceased or reduced __________________________
 
_______ Disability
  Who does this apply to?  ___self  ___spouse  ___mother  ___father
  Date disability began __________
  Amount of disability or benefits to be received in 20__    __________________
  Date benefits received or expected to receive _____________
 
_______ Unusual Medical/Dental Expenses
  Who does this apply to?  ___self  ___spouse  ___mother  ___father
  What situation has caused the unusual expense? ________________________
  How much did you pay for medical/dental insurance in 20__?  ______________
  How much did you pay in actual expenses in 20__?  _____________________
  How much did you expect to pay for insurance in 20__?  __________________

Please estimate expected income for 20__ (January to December)
Source Student Spouse Father Mother
   

(if married)

(for dependent students only)
Wages (income earned from work)        
Severance Pay (not included in wages)        
Interest/Dividend Income        
Net Business Income        
Untaxed Pension        
Taxable Pension        
Unemployment Benefits        
Social Security Benefits        
Welfare/TANF        
Child Support Received        
Disability Income        
VA Benefits        
Workman's Compensation        
Other Income - Specify Source        

I/We certify that this information is complete and correct. (All persons for whom information is provided on this form must sign below.)

Signature: ___________________________________________ Date: __________
Signature: ___________________________________________ Date: __________
Signature: ___________________________________________ Date: __________
 Please describe your Special Circumstance below: ____________________________
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Return this form to:

 

York County Community College
112 College Drive
Wells, ME 04090