For Office Use Only Checklist Item 9RLV19 COMMKEY 9REVRQ 2018-2019 REQUEST FOR RE-EVALUATION Please complete this request for a re-evaluation if you are a dependent student and you or your parent(s) financial situation has changed significantly, or, if you are an independent student and you or your spouse’s financial situation has changed, and this change was not reflected on your 2018-2019 FAFSA application Once we have received your 2018-2019 FAFSA information from the Federal Processor, and you have submitted the necessary documentation, you will then be notified through your Stony Brook email explaining whether or not a revision to your initial eligibility has been made For your special circumstance to be considered, all steps must be completed and submitted to our office no later than May 1, 2019 Student Name Stony Brook ID Check the appropriate condition (A, B, C, D, E, or F) under which you are requesting a re-evaluation You must attach a signed typed statement detailing the specifics of your circumstances and any pertinent information that will help us understand your particular situation We will also need a copy of your 2016 Federal Tax Return Transcript or a signed copy of you 2016 Federal Tax Return and 2016 W2 forms LOSS OR REDUCTION OF INCOME - Student, spouse, or parent(s) earned money in 2016 and A have since experienced a loss or reduction of income To qualify, documentation must be provided verifying the person’s employment status has changed Please indicate the reason below: Employment termination** Retirement Disability Job change Work hour reduction** Effective date: **Note: If the loss/reduction of income is due to employment termination or work hour reduction the family must wait weeks from the effective date before submitting this form If submitting your request for either of these two scenarios, the form may only be submitted after July 1, 2018 Health Science students may submit the form after May 1, 2018 Additional Documentation: B Letter from employer stating termination date Proof of Unemployment Compensation Benefits Documentation of nontaxable income (i.e pension, worker’s comp, etc.) Most recent pay stubs (up to weeks) LOSS OF UNTAXED INCOME OR BENEFIT - Student, untaxed income benefit (i.e, child support, disability, etc.) Additional Documentation: C • • • • spouse, or parent(s) have lost some type of • Letter or statement from agency confirming loss of benefit and actual amount received from 7/1/18-6/30/19 DIVORCE, SEPARATION – You or Your parents separated or divorced after filing 2016 taxes Additional • Copy of Divorce Decree or Separation Documentation Documentation: D DEATH OF PARENT OR SPOUSE – A parent or spouse has died in 2016 Additional • Copy of Death Certificate Documentation: E F HEALTHCARE AND DENTAL EXPENSES - Attach receipts for 2016 healthcare expenses you paid out of pocket, plus Explanation of Benefit (EOB) from the insurance company OTHER SIGNIFICANT CHANGE IN FINANCIAL SITUATION - Student, spouse, or parent(s) have experienced a change that did not result from one of the above listed conditions Important note to business owners: If you are expecting a loss of income for 2018, please note that due to the unpredictable nature of business income, we cannot make a final decision on an appeal of this nature until the 2018 federal income tax return transcript is available for verifying income Stony Brook ID Estimated Income The following sections require you to provide your expected income from July 1, 2018 to June 30, 2019 Include all income received from July 1st until now and estimate the amounts to be received from now until June 30th Complete each section in its entirety If you not receive or not expect to receive a particular source, indicate $0 If you are completing this form prior to July 1st, you will not complete the “Actual” column, but MUST complete the “Estimated” and “Total” columns Actual (7/1/18 to Today) Gross Income from Work (attach pay stubs) by father/step-father Estimated (Today to 6/30/19) Total $ + $ = $ by mother/step-mother $ + $ = $ by student $ + $ = $ by student’s spouse $ + $ = $ $ + $ = $ $ + $ = $ $ + = $ Alimony/Spousal Support $ + $ = $ Child support received for all children $ + $ = $ Other Income: $ + $ = $ Other Income: $ + $ = $ Unemployment Benefits received by Severance Package/Retirement Benefits received by Disability/Worker’s Compensation received by Certification We have completed all sections of this form and the information contained herein is true and complete to the best of our knowledge We also understand that if our financial situation changes during the academic year we will notify the appropriate Financial Aid Office immediately Student Signature/Date Parent Signature/Date PLEASE NOTE: ALL sections of this form must be completed and the required documentation must be attached Your request for a re-evaluation will be held until ALL the required information AND documentation is received Please return this completed form along with the required documentation to the appropriate financial aid department WARNING: If you purposely provide false or misleading information, you may be fined up to $20,000, sent to prison or both Financial Aid Mailing and Contact Information Please mail or fax all documents to the appropriate financial aid department listed below Be sure to include the student’s name and Stony Brook ID on all correspondence Schools of Nursing, Social Welfare, Health Technology and Management, and the Graduate Programs in Public Health and Nutrition: Health Sciences Office of Student Services Health Sciences Tower Level 2, Room 271 Stony Brook, NY 11794-8276 Telephone: 631-444-2111 Fax: 631-444-6035 All Other Graduate and Undergraduate Programs Office of Financial Aid and Scholarship Services Administration Building Room 180 Stony Brook, NY 11794-0851 Telephone: 631-632-6840 Fax: 631-632-9525