DSC17
Dependent Special Conditions
Academic Year 2016-2017
The Department of Education recognizes that special conditions may exist for families who have suffered major
reductions in income for various reasons during 2015 or 2016. For those families, the 2015 tax return does not
accurately reflect the current financial status. If your family’s income has been significantly reduced, you should
complete this form, attach documentation and return it to the Financial Assistance Office for further consideration of
your 2016-2017 eligibility for aid. Please read carefully all instructions to complete this form. You must be sure to
provide copies of all documentation requested. Incomplete request submittals will NOT be evaluated.
A. Student Information
Student Last Name
Student First Name
Student M.I.
Student Street Address
City
Student ID Number
Student Date of Birth
State
Zip Code
Student Primary Phone Number
Student Email Address
Student Alternate Phone Number
B. Explanation of Reduced Income
Please review the following reasons and select one that best describes your circumstances:
Parent has retired, been unemployed for at least two full months, or will experience a change in employment status
due to enrollment in a post-secondary institution. Attach verification (i.e. Statement from employer indicating last date
worked, or DD214.) Effective date of new employment status:
Untaxed income has ceased or been reduced. Attach verification. Date of change:
Permanent and total disability of applicant or spouse. Attach verification. Date of disability:
Death of spouse, which occurred AFTER January 1, 2015. Attach a copy of death certificate. Date of death:
One-time lump sum payment received (i.e. severance, inheritance, lottery, etc.)
C. Dependent Student’s Income Information
Provide a written explanation detailing all reasons your family’s income has been reduced. Attach additional pages as necessary.
Page 1 of 4
DSC17
Student ID:
D. Projected 2016 Income Worksheet
Complete the Projected 2016 Income Worksheet. Provide a separate statement and documentation (copies of pay stubs, etc.)
explaining how you arrived at these projections.
Projected 2016 Income Worksheet
Parent 1 Income
Parent 2 Income
Unemployment
(Gross Wages)
(Gross Wages)
Benefits
Untaxed Income
Jan
$
$
$
$
Feb
$
$
$
$
Mar
$
$
$
$
Apr
$
$
$
$
May
$
$
$
$
Jun
$
$
$
$
Jul
$
$
$
$
Aug
$
$
$
$
Sep
$
$
$
$
Oct
$
$
$
$
Nov
$
$
$
$
Dec
$
$
$
$
Totals $
$
$
$
E. 2016 Gross Taxed and Gross Untaxed Income
Using totals from your Projected 2016 Income Worksheet, complete gross taxed and gross untaxed income sections
below with income your family expects to receive from January 1, 2016 until December 31, 2016 (prior to exemptions,
adjustments, or deductions). If zero, enter zeros. Attach a statement explaining how your family’s living expenses are
provided.
2016 Gross Taxed Income
Parent 1 Income
Parent 2 Income
Wages, salaries, and/or tips
Severance pay
Pensions and Annuities
Interest and dividend income
Business or farm income
Capital gains
Income received from rents after expenses paid for mortgage
interest, taxes, and insurance
Alimony to be received
Unemployment compensation
Any other untaxed income
TOTAL 2016 GROSS TAXED INCOME: $
$
Page 2 of 4
DSC17
Student ID:
2016 Gross Untaxed Income
Payments to Tax-deferred Pension & Savings Plans (paid directly or
withheld from earnings). Include untaxed portion of 401k and 403b plans
Social Security benefits (SSI or disability) received by student, children or
spouse, if married
Retirement or Disability Benefits
Parent 1 Income
Parent 2 Income
$
$
$
$
$
$
Workers’ Compensation
$
$
Welfare benefits including TANF (excluding Food Stamps)
$
$
Untaxed portion of pensions
Living & Housing allowances (excluding rent subsidies for low income
housing) for clergy, military and others. Include CASH payments and cash
value of benefits. Don’t include the value of on-base military housing or the
value of basic military housing allowance.
Child Support or Maintenance payments which will be received for ALL
children
Veteran’s Benefits, except Student’s Educational Benefits
$
$
$
$
$
$
$
$
Railroad Retirement Benefits
Any other Untaxed Income and Benefits such as Black Lung Benefits,
Refugee Assistance, etc.
$
$
$
$
TOTAL 2016 GROSS UNTAXED INCOME: $
$
F. Tax Returns and W2s
You must attach signed copies of student and parent 2015 Federal Tax Return(s) and 2015 W2s.
G. Checklist, Certification, and Signatures
Incomplete Special Conditions Requests will be returned or denied. Please review the form and initial each
item indicating you have provided all requested documentation.
Step A, check your reason for submitting the application and attach verification as requested.
Step B, write a detailed explanation why the application is being submitted.
Step C, complete the Projected 2016 Income Worksheet leaving NO blanks and provide
documentation.
Step D, complete both gross taxed and gross untaxed income tables.
Step E, attach signed copies of student and parent 2015 tax return and all 2015 W2s.
(See back page for certification and signatures.)
Page 3 of 4
DSC17
Student ID:
By signing this form I certify that all the information reported is true. I understand that purposely submitting
false or misleading information is a federal offense punishable by fines or jail sentence or both.
Student Signature
Date
Parent Signature
Date
Submit this worksheet and required documents to:
Office of Financial Assistance
Cameron University – North Shepler #301
2800 West Gore Boulevard
Lawton, OK 73505-6320
FAX: 580-581-2556 | EMAIL: financialaid@cameron.edu
Page 4 of 4