Name of Student
Date of Birth
Student ID
Phone Number
If you have one of the special circumstances listed below, that might affect the amount you/your family are expected to contribute towards your education, please call (919) 209-2036 to make an appointment after you have completed this form and have proper documentation attached to bring with you to your appointment. This documentation will allow the Financial Aid Office to determine if an adjustment may be made. The family contribution may or may not be adjusted, and you will be notified after the information is reviewed. If your income has not SIGNIFICANTLY changed from 2017, please do not complete this form.
  1. TUITION EXPENSES AT AN ELEMENTARY OR SECONDARY SCHOOL

    If you/your parents paid private elementary or secondary school tuition for family members other than yourself for a reason other than choice, attach a signed statement of why it was necessary to pay private school tuition. Also attach documentation of the amount of tuition (not fees, room, or board) paid in 2017. Acceptable documentation would be a statement from the school of the amount of tuition paid in 2017.

  2. UNUSUAL MEDICAL OR DENTAL EXPENSES NOT COVERED BY INSURANCE

    If you/your parents paid unusually high medical and/or dental expenses in 2017, attach a copy of the 2017 tax return Schedule A – Itemized Deductions. If you did not file a Schedule A, attach statements from doctors, dentists, hospitals, etc. indicating the amount you paid in 2017. Do not include any amount reimbursed by the insurance company.

  3. LOSS OF EMPLOYMENT

    If your parents earned money in 2017 and have lost his/her job for at least ten weeks in 2018, attach a signed statement of the loss of employment and the date the employment ended and complete item #8. If you are an independent student and you or your spouse worked full-time in 2017 and have lost a job in 2018, attach a signed statement of the loss of employment and the date the employment ended and complete item #8.

  4. LOSS OF NONTAXABLE INCOME OR BENEFITS

    If you/your parents/your spouse received unemployment compensation or some untaxed income or benefit in 2017 and have completely lost that income or benefit for at least ten weeks in 2018, attach a signed statement of the type of income or benefit lost and the date the income or benefit ended and complete item #8.

  5. SEPARATION OR DIVORCE

    If you/your parents have separated or divorced, attach a copy of the separation or divorce agreement. If you do not have a separation or divorce agreement, attach a signed statement. Complete item #8.

  6. DEATH

    If your parent/spouse received income in 2017 and has died, attach a copy of the death certificate. If the death certificate is not available attach a statement. Also complete item #8.

  7. OTHER CIRCUMSTANCES

    If your family has unusual financial circumstances not identified on this form, attach an explanation and complete item #8.
    (Example: One-time income from 401K distribution)

  8. ESTIMATED INCOME FOR 2018 CALENDAR YEAR

    If you are divorced or separated, include only your income information. If your parents are divorced or separated, include only your custodial parent’s income information. If your custodial parent has remarried include their spouse’s information. If the loss of income is due to the death of your spouse/parent, include only your income information/surviving parent’s income information. Please provide documentation for any amount listed below. Examples of acceptable documentation would be a copy of current unemployment benefits, a copy of last check stub from job lost, and a copy of current check stub from current job. Also, include copies of your 2017 and 2018 Federal tax forms & W-2 Forms (if available), (and your spouse’s if you are married or parent’s if you are considered dependent for Federal aid purposes).

Note: Write in Zero (0) if an item does not apply.
January 1, 2018 – December 31, 2018
Taxable
Parent 1
Parent 2
Student
Spouse
Wages, Salaries, Tips
Pensions
State Unemployment Benefits
Alimony
Other Taxable Income: Specify Source(s)
Untaxable
Parent 1
Parent 2
Student
Spouse
Social Security Benefits
Aid to Families with Dependent Children (AFDC)
Child Support Received
Other Untaxed Income Benefits
Total Anticipated Income
Cash and Savings
Assets
* Do not include the value or debt of the home
Parent(s)
Value
Debt
Other real estate and investments*
Business and farm
Student/Spouse
Value
Debt
Other real estate and investments*
Business and farm

*By signing this form, if adjustments are needed, I authorize Johnston Community College Financial Aid Office to make changes electronically on my behalf.

Each person signing below certifies that all of the information reported is complete and correct

WARNING:
If you purposely give false or misleading information, you may be fined, sent to prison, or both.
Student Signature


Student ID Number
Date
Student's Spouse


Date


Parent Signature: (required for dependent students)


Date


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