APPLICATION FOR DISADVANTAGE LOAN PROGRAMS
HPSL – HEALTH PROFESSIONS STUDENT LOAN
LDS – LOANS FOR DISADVANTAGE STUDENTS
Student Name: ________________________________ Student I. D. Number: ___________________
Permanent Address: ____________________________________ Phone Number: ________________
Street Address
City
State
Zip
Checklist:
□ Complete the 2016-2017 Free Application for Federal Student Aid (FAFSA) with parent information. If you
have already submitted this form without parent information, please log into www.FAFSA.GOV and submit a
correction to include your parents’ information using the date retrieval tool.
□ Complete all sections of the application and sign.
□ Obtain and attach all 2015 IRS Federal Tax Return Transcripts for the student, their spouse (if applicable) and
your parent(s). An IRS Federal Tax Return Transcript can be obtained by visiting www.irs.gov or by calling
1-800-908-9946. You may provide a signed copy of IRS Federal Tax Returns instead of the tax transcript.
□ Provide copies of all W2’s, if required
□ Collect and submit any other required documentation, such as child support paid or received.
□ Submit all information to the Student Financial Aid Office at the College of Podiatric Medicine
SECTION 1: HOUSEHOLD INFORMATION
List the people in the student’s household. Include: the student; your spouse; your children if you will provide
more than half their support between July 1, 2016 – June 30, 2017; and any other people that now live with you
and you provide more than half their support, and will continue to provide more than half their support
between July 1, 2016 – June 30, 2017.
Student’s Household
Member’s Name
Date of
Birth
Relationship to Student
Name of college they will attend
during 2015-2015 (if applicable)
List the people in your parents’ household. Include: your parents; your parents’ other children if your parents
will provide more than half of their support between July 1, 2016– June 30, 2017; and any other people that
now live with your parents if your parents will provide more than half of their support, and will continue to
provide more than half their support between July 1, 2016 – June 30, 2017. Please contact the Student
Financial Aid Office if you have questions regarding which parents / stepparents should be included on this
form.
Parent(s) / Stepparent
Date of
Birth
Social Security Number
Month and Year Married
Parent(s)Household
Member’s Name
Date of
Birth
Relationship to Parent
Name of college they will
attend during 2016-2017 (if
applicable)
SECTION 2: TAX FILING STATUS
Student & Spouse Filing Status
□ I completed my 2015 federal income tax return.
If you filed with a spouse, and did a joint federal tax
return, attach all copies of you and your spouse’s
2015 W-2’s
□ I’m not going to file a 2015 federal income tax
return. However, in 2015, I earned:
$_______________. Attach all copies of you and
your spouse’s (if applicable) 2015 W-2’s.
□ I’m not going to file a 2015 federal income tax
return, and I did not work in 2015.
Parent(s) Filing Status
□ My parents completed their 2015 federal income
tax return. If your parents filed a joint federal tax
return, attach all copies of their 2015 W-2’s
□ My parents are not going to file a 2015 federal
income tax return. However, in 2015 my parent’s
earned: $_______________. Attach all copies of
your parent’s 2015 W-2’s.
□ My parents are not going to file a 2015 federal
income tax return, and did not work in 2015.
SECTION 3: UNTAXED INCOME INFORMATION
Do not leave any question in this section blank. Enter “0” if no income was received from one of the sources
listed below. Note: You must provide the required documentation if requested
Student/Spouse
$__________
Additional Income Information
For Calendar Year 2015
(Provide documentation if requested)
Military Combat Pay or Special Combat Pay that was taxable
(FOR MILITARY VETERAN’S ONLY). Only include amount that was taxable
and included in your Adjusted Gross Income. Combat pay is reported on
your 2015 W-2 in Box 12, letter Q.
Parent(s) or
Stepparent
$__________
Documentation Required: Copy of 2015 W-2 from employer where you
earned combat pay.
Child support paid because of divorce or separation. Don’t include
support for children in your (or your parents’) household.
$__________
$__________
$__________
Documentation Required: Statement from the Bureau of Child Support,
or signed statement from the parent who received the payments.
Documentation must include the names of the children and the total
amount received for each child in 2015.
Taxable earnings from Federal Work Study or other need-based work
programs.
Documentation Required: Copy of 2015 W-2 from employer where you
earned Federal Work Study.
Earnings from work under a cooperative education program. Enter here
any amounts you earned from work under a cooperative education
program offered by an institution of higher education. Do not include
Federal Work Study or Graduate Assistantships.
$__________
$__________
$__________
Documentation Required: Copy of 2015 W-2 from employer of your coop and documentation from your college showing your job was a co-op.
Student grant, scholarship, and fellowship aid, including AmeriCorps
awards reported to the IRS in your (or your parents’) 2015 Federal Tax
Return.
$__________
$__________
Documentation Required: Signed copy of 2015 Federal Tax Return with
all pages and schedules, showing amount reported in scholarships and
grants.
Student/Spouse
Untaxed Income Information
For Calendar Year 2015
(Provide documentation if requested)
Parent(s) or
Stepparent
Child Support received for all children. Don’t include foster care or
adoption payments.
$__________
Documentation Required: Statement from the Bureau of Child Support
or signed statement from the parent who made the payments.
Documentation must include the names of the children and the total
amount paid for each child in 2015.
$__________
Federal Nutrition Assistance Program (SNAP) received by any member of
the household.
$__________
$__________
Documentation Required: Statement from the agency that issued the
SNAP benefit or other documentation that includes the amount received
in 2015.
Payments to tax-deferred pension and/or savings plans (paid directly or
withheld from earnings), including but not limited to amounts reported
on the 2015 W-2 Form in box 12 codes D,E,F,G,H, and S.
$__________
$__________
$__________
Documentation Required: Copy of 2015 W-2 from employer(s) where
you made payments to a tax deferred pension.
Housing, food, and other living allowances paid to members of the
military, clergy, and others (including cash payments and cash value of
benefits).
$__________
$__________
Documentation Required: Copy of 2015 W-2 from employer(s).
Veteran’s non-education benefits such as Disability, Death Pension, or
Dependency & Indemnity Compensation (DIC) and/or VA Educational
Work-Study allowances.
$__________
$__________
Documentation Required: Statement showing amount received in 2015.
Untaxed portions of IRA Distributions reported on 2015 Federal tax return
(Line 15a-15b on 1040, or Line 11a-11b on 1040a). Please check box if
this was a rollover.
$__________
Rollover
$__________
If this was a rollover please mark box provided.
Untaxed portions of Pension & Annuities reported on 2015 Federal tax
return (Line 16a-16b on 1040, or Line 12a-12b on 1040b) Please check
box if this was a rollover.
Rollover
Rollover
$__________
Rollover
If this was a rollover please mark box provided.
Any other untaxed income or benefits not reported elsewhere. Examples
include but are not limited to: worker’s compensation, untaxed portions
of railroad retirement benefits, Black Lung Benefits, disability, and
combat pay not included in AGI on tax return (tax filers only).
$__________
DO NOT INCLUDE student aid, earned income credit, child tax credit,
welfare payments, untaxed Social Security benefits, Workforce
Investment Act educational benefits, combat pay, benefits from flexible
spending arrangements (e.g., cafeteria plans), foreign income exclusion or
credit for federal tax on special fuels.
Documentation Required: Statement from the agency providing the
funds. Combat pay is reported on 2015 W-2 in Box 12, letter Q.
$__________
SECTION 4: PARENT ASSETS
What is your parents’ total current balance of cash, savings, and checking accounts: $______________
What is the net worth of your parents’ current investments:
$______________
Investments include real estate (do not include the home they live in), trust funds,
money market funds, mutual funds, certificates of deposit, stocks, stock options,
bonds, other securities, installment and land sale contracts (including mortgages
held), commodities, etc. Include the value of all college savings plans (529 and prepaid tuition credit programs) owned by the parent or the student. Do not include
the value of life insurance policies, retirement plans, pension plans, annuities, noneducational IRA’s, Keogh plans etc. The value of education IRA’s must be included.
If your parent(s) own their own business, what is the net worth of that business:
Include land, buildings, machinery, equipment, inventory, etc.
$______________
Circle One
Is the business owned and controlled by the student’s parent(s)?
Yes
No
Does the business employ less than 100 full-time employees?
Yes
No
What is the net worth of your parents’ investment farm:
$______________
Don’t include a farm that you live on and operate
SECTION 5: SIGNATURES
This form must be signed by the student and spouse (if d married), or by the student and at least one parent.
By signing this application you hereby affirm that all information reported on this form and any attachment
hereto is true, complete, and accurate to the best of your knowledge. You understand that the Student
Financial Aid Office at Kent State University will correct the FAFSA application, as necessary, based on the
information submitted. You agree that you understand that if you received federal student aid based on
incorrect information, you will need to repay it. You may also be required to pay fines and fees. By signing
below, you certify that you (1) will use federal and/or state student financial aid only to pay the cost of
attending an institution of higher education, (2) are not in default on a federal student loan or have made
satisfactory arrangements to repay it, (3) do not owe money back on a federal student grant or have made
satisfactory arrangements to repay it, (4) will notify your college if you default on a federal student loan and
(5) will not receive a Federal Pell Grant from more than one college for the same period of time.
_______________________________________________________________ _____________________
Student Signature
Date
_______________________________________________________________ _____________________
Student’s Spouse Signature (if applicable)
Date
______________________________________________________________
Parent/Stepparent Signature
_____________________
Date
STUDENT FINANCIAL AID OFFICE – COLLEGE OF PODIATRIC MEDICINE
6000 Rockside Woods Blvd  Independence, OH 44131
216-916-7490  FAX 216-916-7382  kwrigh32@kent.edu