College of DuPage
Office of Student Financial Assistance Last Name:
2016-2017 Special Conditions Review Request
First Name:
Student ID:
Important information:  You must be able to document your special condition(s). Required documentation for each category is listed below. Additional documentation may be required upon review of your circumstances. The review process cannot be completed until all requested information and documentation has been received.  If you were not originally selected for verification, you may still need to verify the information you reported for 2015 on your FAFSA by submitting 2015 IRS Tax Transcripts and/or additional documentation.  Not everyone who submits a review request will receive additional aid. If the EFC from your FAFSA is “0”, you already have the maximum eligibility. Changes to 2016 income that are not a significant reduction from the income reported on your FAFSA (calendar year 2015) may not produce a change in eligibility.  If you have questions, please contact the Office of Student Financial Assistance at (630) 942‐2251 or financialaid@cod.edu for assistance. Please complete the applicable section(s) below, and on the back of this form:
CIRCUMSTANCES
□ Loss of work income due to total,
partial or temporary loss of
employment, or reduction in work
hours. Note: Loss cannot be
voluntary.
□ Student
□ Spouse
□ Father
□ Mother
□ Loss of benefits, such as child
support, alimony, unemployment
benefits, workers’ compensation,
disability benefits, etc.
□ Student
□ Spouse
□ Father
□ Mother
□ Loss of work income due to
illness or injury.
□ Student
□ Spouse
□ Father
□ Mother
□ Divorce, separation, or death.
□ Spouse
□ Father
□ Mother
□ Other loss, reduction or
adjustment to income, such as
unusually high medical expenses, a
one-time disbursement of income or
benefits which changed the family’s
overall income level, etc.
REQUIRED DOCUMENTATION
 Notice from employer stating the date of termination, lay-off, work
reduction, etc. (as applicable).
 Copy of last (most recent) pay stub or earnings statement from each
employer in 2016.
 Award letter from Unemployment Office stating the weekly benefit
amount. (If benefits not received, please explain.)
 Provide estimated income information on page 2 of this form.
 Describe the situation on page 2 of this form.
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Letter or other notification stating the date the benefits ended.
Documentation of the amount of benefits received.
Provide estimated income information on page 2 of this form.
Describe the situation on page 2 of this form. If loss of benefits such as
unemployment benefits or workers’ compensation is due to a return to
work, please provide date returned to work, and a copy of most recent
pay stub or earnings statement.

Letter from employer or appropriate medical professional, verifying the
date the employee became unable to work, and an estimate of when the
employee should be able to return to work.
Copy of last pay stub.
Provide estimated income information on page 2 of this form. You
must report all income that is received in place of work income, such as
workers’ compensation, disability benefits, etc.
Describe the situation on page 2 of this form.
Copy of divorce decree or death certificate (as applicable).
Copy of 2015 IRS Tax Transcripts and W2 forms.
Describe the situation and provide estimated income on page 2.
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2016 – 2017 Special Conditions Review Request
Submit the appropriate documentation to support your circumstance,
such as a copy of your 2015 IRS Tax Return Transcripts showing the
amount of a one-time disbursement of income, or a copy of Schedule A
from your tax return, showing the amount of itemized medical
expenses.
Provide estimated income information on page 2 of this form.
Describe the situation on page 2 of this form.
1
02/02/16
Student Name:
Student ID:
ESTIMATED INCOME INFORMATION:
Provide estimates of all income that is expected to be received by your household for the 2016 calendar year. If a
dependent student’s mother and father, or an independent student and spouse, are both employed (or have other sources of
income) please complete both columns.
Student
Spouse (if married)
Parent 1
Parent 2
$
$
$
$
2016 Income from Work
2016 Unemployment Benefits
$
$
$
$
2016 Social Security Benefits
$
$
$
$
2016 Worker’s Compensation
$
$
$
$
2016 Disability Benefits (NonSSI)
2016 Retirement Benefits
$
$
$
$
$
$
$
$
2016 Child Support
Received
Paid
2016 Alimony
Received
Paid
2016 Cash Support (from
Friends, Relatives, etc.)
Other: ____________
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
EXPLANATION OF SITUATION: (You may attach an additional page if there is not enough space below.)
CERTIFICATION: I/WE certify that all information on this form is true, complete and accurate. Upon request I agree to provide additional proof of the information reported on this form. Warning: If you purposely give false or misleading information, you may be fined up to $20,000, sent to prison, or both. Student Signature Parent Signature (if dependent) Spouse Signature (if married) Date Please return this form to: College of DuPage, Office of Student Financial Assistance – SSC 2220 425 Fawell Blvd., Glen Ellyn, IL 60137 FAX (630) 942‐2151 EMAIL: financialaid@cod.edu The college will not discriminate in its programs and activities on the basis of race, color, religion, creed, national origin, sex, age, ancestry, marital status, sexual orientation, arrest record, military status or unfavorable military discharge, citizenship status, physical or mental handicap or disability (Board Policy 5010; 20‐5) 2016 – 2017 Special Conditions Review Request 2 02/02/16