2015‐2016 Special Condition Request 


To   submit   the   completed   form:           (SPCOND)  

In   person:    MT   One   Stop,   Student   Services    And   Admissions   Center   (SSAC)   –   Room   210  

Mail:    MTSU,   MT   One   Stop,   SSAC   Room   260,   1301   East   Main   Street,   Murfreesboro,   TN    37132  

Fax:    (615)   898 ‐ 5167    










Name: Student ID: M


Street Apt. # City State Zip

Email Address: @mtmail.mtsu.edu Phone: ( )

You may request a review of your FAFSA if you or your family experiences one of the extenuating circumstances listed below. If selected for verification by FAFSA, you must complete verification before submitting this request. Please note the review process takes approximately 3-4 weeks after you submit all required paperwork; you will be notified of our review decision by email.

You must include with your request:

A signed, detailed letter of explanation of your situation

A copy of all 2014 U.S. Income Tax documents (signed tax returns – physical signature, not electronic signature sent to

IRS; all schedules, worksheets, W-2’s,1099’s,etc.for parents and student/spouse)

All documentation that applies to your situation (as outlined below):

Extenuating Circumstance

Significant loss of income/loss employment

(Student, Parent(s), Spouse)

* Requests involving self-employment, commission, tips or other variable income will generally not be reviewed until the end of the 2015 year due to the complexity of estimating yearly income. Requests may also be delayed until the end of 2015 if income is undeterminable or until the affected member has obtained employment.

**If requesting the review of a one-time payment and the payment was not a rollover or transfer, you must provide documentation for what the payment was used for (ex. paid receipts for extenuating circumstances)

Death of a parent or spouse

that has taken place after the 2015-2016 FASFA has been filed.

Documentation Required

(if applicable)

Must Include:

 Last pay stub from previous employment (current year)

Date of unemployment: / /

 Current pay stub of affected person (if applicable)

Date of new employment: / /

 Other household member’s (parent/spouse/student) most recent pay stub

 Proof of unemployment and / or benefits (if applicable)

Date benefits began: / /

May be applicable:

 Proof of severance package benefits

 Proof of pension income

 Proof of one-time payment (1099, Roth IRA


Separation / divorce of parent or student

that has taken place after the 2015-2016

FASFA has been filed .

Out-of-pocket medical expenses paid

NOTE: These are expenses not paid by your insurance provider. These are out-of-pocket expenses that you (or parent) have already paid to the provider.

Loss of Child Support Income

 Death certificate or obituary notice

 Most recent pay stub of surviving parent/student

 Life insurance benefits statement

 Final divorcee decree

 Legal complaint for divorce

 Proof of separation (2 separate addresses – utility bills, etc.)

 Most recent pay stub from student and/or parent

 Proof of out-of-pocket payment (cancelled checks, receipts, etc.)

 Proof of disability income

 Schedule A from 2014 Income Tax return

 Proof & amount of court-ordered child support

A. Number of Household Members and Number in College

Complete each column below with the name, age and relationship of every person that can be included in the household size, as defined below. Indicate whether or not the household member will be attending college at least half-time as a degree seeking student between July 1, 2015 and June 30, 2016.

 Dependent students – you must include your parents, even if you do not live with them. Also include your parents’ other children and other people who live with your parents if your parents will provide more than half of their support during the above timeframe.

 Independent students – you must include your spouse, you or your spouse’s children that you provide more than half of their support as well as any other people that live with you and you provide more than half of their support during the above timeframe.

Full Name Age Relationship Is the household member attending at least half-time in a degree, diploma or certificate program at an eligible postsecondary educational institution any time between

July 1, 2015 and June 30, 2016? If yes, list the name of the college.

B. Verification of Child Support Paid

Self  No  Yes Middle TN State Univ.

 No  Yes

 No  Yes

 No  Yes

 No  Yes

 No  Yes

Did you (or your parent if dependent / spouse if independent) pay child support in 2014?

Name of Person Who Paid

Child Support

Name of Person to Whom

Child Support Was Paid

Name and Age of Child for

Whom Child Support was


Yes No

Amount of Child Support Paid in 2014

Note: If we have reason to believe that the information regarding the child support paid is not accurate or is conflicting with the amount on FAFSA, we will require additional documentation .

C. Receipt of SNAP (formerly known as Food Stamps Program) Benefits

The parent/student must certify whether or not a member of the parents’/student’s household (listed in Section A) received benefits from the Supplemental Nutrition Assistance Program (SNAP) sometime during 2013 or 2014. SNAP may be known by another name in some states. Submit proof of benefits if you answered ‘no’ to this question on FASFA and are marking ‘yes’ on this worksheet. Check the appropriate box below.

 Yes. A member of the parents’ / student’s household received SNAP Benefits during 2013 or 2014

 No. No member of the parents’ / student’s household received SNAP Benefits during 2013 or 2014 .

D. Estimate of 2015 Income

In order for MTSU to consider a change of income between 2014 and 2015, we must estimate what your 2015 tax return will be based on the information below and your 2014 tax information. Please complete the following charts listing all income from

January 2015 to December 2015. Do not leave any section blank . Place a zero in the item(s) that do not apply. Incomplete forms will delay the review of your request. Parental information is only required for dependent students (as defined by FAFSA).

(You must provide an explanation and/or proof of all income listed below.)

Estimated 2015 Taxable Income

Yearly wages, salaries, and tips

Father Mother Student Spouse

Yearly severance pay

Yearly pensions and annuities

Yearly interest and dividends

Taxable refunds from previous tax year

Yearly business income

Yearly farm income

Yearly capital gains

Yearly rents from rental property

Yearly alimony

Yearly unemployment benefits

Yearly retirement income

IRA distribution / 401K distribution

Social Security Benefits

Yearly other taxable income *

Total 2015 Taxable Income

Estimated 2015 Untaxed Income

Yearly payments to retirement plans

Father Mother Student Spouse

Yearly child support received for all children

Yearly payments to pension/ savings

Yearly work-study earnings

Yearly workers compensation

Inheritance / other benefits received from a family member*

Yearly living & housing allowance for clergy, military, etc. (Includes BAS/BAQ cash allotments)

Yearly veteran’s non-educational benefits, such as Disability Death Pension or Dependency &

Indemnity Compensation and/or VA Educational work-study allowances

Yearly financial support paid on the student’s behalf * (Includes funds from other family members or 3 rd


Yearly other untaxed income *

Total 2015 Untaxed Income

*If you listed “yearly other taxable income”, “inheritance/other benefits received from a family member”, “yearly financial support paid on the student’s behalf”, or “yearly other untaxed income”, please explain below:

E. Asset Information

Do not leave any section blank . Place a zero in the item(s) that do not apply. Incomplete forms will delay the review of your request. Parental information is only required for dependent (as defined by FAFSA) students.

Asset information based on the date the original FAFSA was filed.

Cash, savings and checking accounts.

Enter your total balance as of the day the original FAFSA was signed.





Real estate value: List the value of rental property, land, second or summer homes. Do not include the home you live in.

$ $

Real estate debt: Amount owed on investment real estate. Do not include the amount you owe on the home you live in.

Investments: Trust funds, UGMA and UTMA accounts (exclude if custodian and not owner of account), money market funds, mutual funds, certificates of deposit, stocks, stock options, bonds, other securities, commodities, installment and land contracts (including mortgages held).

Qualified educational benefits or education savings accounts:

Coverdell savings accounts, 529 college savings plans and the refund value of 529 prepaid tuition plans.

Business value : Include the market value of land, buildings, machinery, equipment, inventory, etc. (value minus debt applicable to business only).

Name of business: ________________________________________________

Do not include the value of a small business if your family owns and controls more than 50% AND the business has 100 or fewer employees.

Farm value: Include the market value of land, buildings, machinery, equipment, inventory (value minus debt applicable to farm only).

Do not include farm value, if the farm is the principal place of residence for the student and family (spouse, if applicable and parents of dependent student)

AND the student (or parents of a dependent student) materially participated in the farming operation.











Small business value: Percentage of family ownership: _________

(100 or fewer employees) Number of employees: _________

Name of business: _____________________________________________

$ $

F. Certifications and Signatures

Students, please initial to indicate your understanding of the following statements:

I understand the Special Condition review process is based upon the estimated income and documentation that I

provided for 2015 and if the 2015 actual income is greater than 10% of the estimated income, I may be denied future


I understand I may be required to repay any and all financial aid received as a result of the Special Conditions process

if I falsify information.

I understand that my FAFSA data may be verified as part of this process. If I am selected for verification by FAFSA, I

must complete the verification process before my Special Condition request can be reviewed.

I understand that additional information may be required after initial documentation is submitted.

I understand that I must inform the MT One Stop if my circumstances change for the current year.

I understand that the review process may take 3-4 weeks after I submit all required paperwork.

I understand that I must have a Partners in Education (PIE) form on file with MTSU in order for the MT One Stop or the

Financial Aid Office to discuss and/or release any information about my Special Condition request to a third party

(i.e. parent, spouse, guardian, relative, etc). Otherwise, the office will only release information to me, the student. The

PIE form can be obtained at the following website: http://www.mtsu.edu/pie/ .

Student Signature Date Parent/Spouse Signature Date