Financial Aid & Student Records
P.O. Box 6000, Binghamton, NY 13902-6000
(607) 777-2428 FAX: (607) 777-6897
Admissions Center-Room 112
email: finaid@binghamton.edu
http://bingfa.binghamton.edu
2016-2017 SPECIAL CIRCUMSTANCES FORM
Student’s Name___________________________________________ B-number___________________________
SECTION A: SPECIAL CIRCUMSTANCES FOR CONSIDERATION: You are submitting this form to
appeal your financial aid award offer due to special circumstances. Please review and indicate
below which special circumstance applies to you. Required documentation (listed below) based on
special circumstances must be submitted along with this form, including a signed statement
detailing the specifics, to avoid delays in a timely determination for you.
SPECIAL
CIRCUMSTANCE
FOR A
DEPENDENT
STUDENT
FOR AN
INDEPENDENT
STUDENT
 Loss of Employment
Your or your
parent(s’) income
earned in 2016
will be less than
that earned in
2015.
Your or your
parent(s) received
benefits in 2015
which have
ceased or been
reduced in 2016.
Your (and/or your
spouse’s) income
earned in 2016
will be less than
that earned in
2015.
You (and/or your
spouse) received
benefits in 2015
which have
ceased or been
reduced in 2016.





2015 IRS Tax Transcripts for all
2015 W-2 wage statements for all
Last pay stub showing year-to-date earnings
Termination notice from employer
Unemployment Benefit notice




2015 IRS Tax Transcripts for all
2015 W-2 wage statements for all
Original 2015 Benefit statement listing total received
Revised Benefit statement listing updated amount to
receive and effective date
Your parents
separated or
divorced AFTER
filing the FAFSA
but no later than
12/31/2016.
A parent has died
AFTER filing the
FAFSA.
You and your
spouse separated
or divorced AFTER
filing the FAFSA
but no later than
12/31/2016.
Your spouse has
died AFTER filing
the FAFSA.




2015 IRS Tax Transcripts for all
2015 W-2 wage statements for all
Divorce decree/separation agreement or
Proof of separate addresses
Paid 2015
medical expenses
by you or your
parents
You or your
parents received
a one-time, lump
sum payment in
2015.
Paid 2015
medical expenses
by you or your
spouse
You (and/or your
spouse) received
a one-time, lump
sum payment in
2015.
 2015 IRS Tax Transcripts for all
 2015 W-2 wage statements for all
 Proof of all out-of-pocket paid expenses for 2015
 Other Loss of Income





Alimony
Child Support
Retirement/Pension
Social Security (taxed)
Worker’s Compensation
 Separation or Divorce
 Death of a Parent or Spouse
 Medical/Dental Expense*
One
Time (Lump Sum) Payment
Received
REQUIRED
DOCUMENTATION
 2015 IRS Tax Transcripts for all
 2015 W-2 wage statements for all
 Applicable death certificate
 2015 IRS Tax Transcripts for all
 2015 W-2 wage statements for all
 Documentation showing one-time, lump sum
payment and what it is from.
 A detailed letter indicating what these funds were
used for and the balance remaining at this time
*Only medical/dental expenses not covered by insurance can be reported. Your AGI will be adjusted only if
the amount of these expenses are determined to be greater than your Income Protection Allowance (IPA).
This allowance is calculated by the federal processor and is based on your FAFSA information.
Important notes about submitting an appeal due to special circumstances: (1) Please be aware that if
you filed your 2016-17 FAFSA and received an EFC = Zero (0), you already receive the maximum in federal
aid. Submitting this appeal will not result in a change to your financial aid offer. (2) If the estimated income for 2016
is approximately the same or higher than the 2015 income listed on the FAFSA (due to receiving unemployment,
severance pay, other untaxed income, etc.), submitting this appeal will not result in a change to your financial aid offer.
SECTION A: PLEASE ATTACH A SIGNED DETAILED STATEMENT EXPLAINING YOUR EXACT SPECIAL
CIRCUMSTANCE.
SECTION B: PROJECTED INCOME AND BENEFITS FROM JANUARY 1, 2016 TO DECEMBER 31, 2016
SOURCE OF INCOME:
MOTHER/
STEPMOTHER
$
STUDENT
Wages, Tips, Salary
FATHER/
STEPFATHER
$
$
STUDENT’S
SPOUSE
$
Interest and/or Dividend Income
$
$
$
$
Unemployment Compensation
$
$
$
$
Worker’s Compensation
$
$
$
$
Pensions and/or Annuities
$
$
$
$
Severance Pay
$
$
$
$
Retirement Benefits
$
$
$
$
Disability Benefits
$
$
$
$
Social Security Benefits (taxable)
$
$
$
$
Child Support
$
$
$
$
Alimony
$
$
$
$
Welfare Benefits
$
$
$
$
Other: _____________________
$
$
$
$
TOTAL OF ALL INCOME:
______________
_____________
____________
___________
Note to business owners: If you have had a loss of business income for 2016, please note that due to the
unpredictable nature of business income, we cannot make a final decision on an appeal until the 2016 federal income
tax return is available for verifying income.
SECTION C: STATEMENT OF CERTIFICATION
All of the information on this form is true and complete to the best of my knowledge. If requested, I agree to provide
further documentation to substantiate the information provided. I understand that all special circumstances are
reviewed on a case-by-case basis and this written request does not guarantee approval and/or may not ultimately
result in actual change of the financial aid already offered. (All persons providing information must sign below.)
___________________________________________________
Student’s signature
______________________________
Date
___________________________________________________
Student’s Spouse’s signature (if applicable)
______________________________
Date
___________________________________________________
Parent’s signature (if student is dependent)
______________________________
Date
HAVE YOU PROVIDED ALL OF THE FOLLOWING?
 Signed, detailed statement of circumstances.
 IRS Tax Transcripts, as applicable.
 All applicable W-2 wage statements.
 All other required documentation, as indicated.
 Appropriate signatures on ALL forms, including this one.
 Student’s Name and B-number on ALL forms.