Special Circumstances - Independent Students

(*) denotes required information.

* Student's Name:

* Name of Person Completing Form:

* Email:

Condition 1 - Changes in Income

Complete this section if your income in 2013 will be less than their income in 2012.

Briefly explain the reasons for the change(s) in income:

Condition 2 - Divorced or Separated Information

If you were recently divorced or separated, but filled a joint 2012 tax return we need the following items:

1. Completed 2012 federal tax form (1040, 1040A, or 1040EZ).
2. 2011 W-2 Forms for you and your spouse.
3. Separation agreement or divorce decree including settlement agreement.
4. Spouse information:

Name:

Phone:

Address:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

All items are needed to make any adjustment.

Check here if this condition applies to you.

After submitting this online form, you will need to send the documents listed above to:

Bradley University
Financial Assistance Office
1501 W. Bradley Avenue
Peoria, IL 61625

You may also fax documents to (309) 677-2798. Please include your name and Social Security number on any documents you mail or fax.

Condition 3 - Extreme Medical or Dental Expenses

You indicated that your family has incurred medical/dental expenses in excess of 10% of your adjusted gross income. Please forward the following:

• Completed 2012 federal tax form (1040, 1040A or 1040EZ), including schedule "A."

Check here if this condition applies to you.

After submitting this online form, you will need to send the documents listed above to:

Bradley University
Financial Assistance Office
1501 W. Bradley Avenue
Peoria, IL 61625

You may also fax documents to (309) 677-2798. Please include your name and Social Security number on any documents you mail or fax.

Condition 4

Use this space to briefly explain any other circumstance you think should be considered:

 

Verification

We cannot process your worksheet without your verification below.

We certify all the information provided to be correct and accurate. We also understand that if the projected circumstances fail to materialize, any financial assistance received because of the conditions is subject to recision on this or subsequent academic years.

Student Verification:

Date:

Spouse Verification:

Date: