ARP: 2021-22 Dependent/Independent Special Conditions: Request Re-Evaluation of Federal Aid Eligibility 1Special Circumstances2Anticipated Income for 01/01/2021-12/31/2021 Complete this form if you (and your spouse, if applicable) have experienced a reduction in income from 2019 to 2020 or 2021. The Financial Aid Office will review the 2019 and 2020 actual income as well as 2021 estimated income and supporting documentation to determine if the student is eligible to receive additional federal student aid funds. (This reevaluation does not affect NY State awards). All special circumstance forms are reviewed on a case-by-case basis and the student will be notified by email of any adjustments. Student's Name(Required) First Last Student's U#(Required) Please indicate whether you are legally considered a dependent or are independent:(Required)Select an optionDependentIndependentPlease select your special condition (see descriptions below):(Required)Select your special conditionInvoluntary Loss of EmploymentRetirementLoss of Un/taxed IncomeLegal Separation or DivorceDeath of ParentOther (Medical/Dental Expenses not covered by insurance, flex spending or HSA, paid in calendar year 2019 and/or 2020. Special Condition Dependent Student Required Supporting Documentation Other DocumentationWe May Request Involuntary Loss of Employment Parent(s) income earned in 2020 and/or 2021 will be less than that earned in 2019. Copy of last pay stub showing year-to-date earnings, termination notice from employer, and a benefit notice from unemployment office In addition to this form completed in its entirety and all of your supporting documents, you may also need to provide the following to the SUNY Poly Financial Aid Office upon request: On a separate sheet of paper write and sign a brief letter indicating the date your financial status changed and explain how it has changed A completed 2021-2022 Verification Worksheet Parent(s) and student’s Tax Return Transcript* (call 1-800-908-9946 or go to www.irs.gov and click link “Get Your Tax Record”) Copies of W2s* for parent(s) and student Retirement Parent(s) income in 2020 and/or 2021 will be less than in 2019. Retirement notice/letter from employer, income received from pensions, investments, IRAs, and other financial instruments Loss of Un/taxed Income Child Support Social Security Worker’s Compensation Alimony Other (explain in letter) Parent(s) received benefits in 2019 which have ceased or been reduced in 2020 and/or 2021. Provide documentation from agency stating total amount received in 2019 and termination date or documentation of updated 2020 and/or 2021 amount. Legal Separation or Divorce Parents have legally separated or divorced AFTER filing the FAFSA Provide a copy of the divorce decree or legal separation agreement. Death of Parent A parent has died AFTER filing the FAFSA. Provide a copy of the death certificate. Other Medical/Dental Expenses (not covered by insurance, flex spending or HSA) paid in calendar year 2019 and/or 2020 Parent(s) medical expenses in 2019 and/or 2020 exceeded 11% of their total income. Provide documentation of proof of payment of medical bills and letter from insurance company showing medical expenses not covered. All information will be kept confidential. The written statement you provide will be a determining factor in the special conditions review. Please provide specific details. All documents submitted become the property of SUNY Poly. Certification: Each person signing below certifies that all of the information reported is complete and correct. The student and one parent of dependent students, whose information was reported on the FAFSA, must sign and date.Date: 02/08/2023Student's Electronic Signature(Required) First Last Student's Phone Number(Required)Parent's Electronic Signature(Required) First Last Parent's Phone Number(Required) Do not leave anything blank. If your answer is zero, enter "0".Income Source: Actual Earnings from WorkLetter(s) from prior employer(s), stating termination dates—on letterhead, signed and dated. A copy of your most recent pay stub(s) showing year-to-date earnings. Record total earnings from January 1st to the date you stopped working.Father's/Stepfather's Income:(Required)Mother's/Stepmother's Income:(Required)Student's Income:(Required)Income Source: Estimated Earnings from WorkIf you have begun a new job(s), provide a copy of your most recent pay stub(s) and estimate your total earnings for the remainder of the year.Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: NET Business IncomeProvide an estimate of your net income for the entire year. Provide documentation supporting any change. (You may be asked to provide the last 3 years of tax returns).Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Total Pension(s)Statement from paying agency showing monthly amount received for the year.Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Unemployment CompensationUnemployment recap showing amount of benefits received. Copy of statement from Unemployment Office showing weekly benefit rate and benefit period. Multiply by the number of weeks you will receive the benefit and record this as your total.Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Other Taxable Income (alimony, capital gains, etc.)Note the source below and record the total amount you will receive for the year. Provide documentation supporting any change from previous year. Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Source(Required) Income Source: Child Support Paid Out for 2019 and/or 2020Note the total you will pay out for the year and provide documentation supporting any change from previous yearFather's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Untaxed Portions of Pensions (Exclude Rollovers)Note the total you expect to receive for the year and provide documentation supporting any change from previous year.Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Child Support Received for 2019 and/or 2020Note the total amount you expect to receive for the year and provide documentation supporting any change from previous year. Include those months for which you have already received payment.Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Worker’s Compensation Copy of benefit statement. Record total expected benefits for the yearFather's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Other Non-taxable IncomeNote source below and record total year income you expect to receive. If there has been a change, provide a copy of a letter from the agency that provided benefits, detailing termination of benefits and copies of summaries of benefits.Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Source(Required) Income Source: Social Security BenefitsCopy of notification of change in benefits. Estimate the total amount in benefits for the year. Include any totals received for the year prior to the benefit change. Be sure to include benefits for all family members.Father's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)Income Source: Supplemental Nutrition Assistance Program (SNAP)Provide statement of benefitsFather's/Stepfather's Income(Required)Mother's/Stepmother's Income(Required)Student's Income(Required)I understand that I must submit proper documentation in order to complete this process. I will provide such documentation to the Financial Aid Office either by emailing it to finaid@sunypoly.edu, by faxing it to 315-792-7220, by mail or in person.(Required) I consent to the following statement:I understand that I must submit proper documentation in order to complete this process. I will provide such documentation to the Financial Aid Office either by emailing it to finaid@sunypoly.edu, by faxing it to 315-792-7220, by mail or in person.CAPTCHAHiddenFor Office Use OnlyHiddenPrior Year Circumstance?Select an optionYesNoHiddenIf so, estimated income accurate?Select an optionYesNoHiddenSpecial Circumstance Approved:Select an optionYesNoHiddenSpecial Circumstance Denied:Select an optionYesNoHiddenSent Letter: HiddenApproved by: HiddenDate Approved - must be mm/dd/yyyy format MM slash DD slash YYYY HiddenOld EFC: HiddenNew EFC:
