Special Circumstances Form - Academic Year 2023-2024

Section A. Student Information

First Name:

Middle initial(s):

Last name:

Street address:

City:

State:

Zip code:

Calvin ID number (If known, otherwise leave blank):

Sibling(s) at Calvin (list name(s) and student numbers(s) of sibling(s) at Calvin in 2023-2024):

Section B: Parents'/Stepparents' Information

Father/Stepfather

Name:

Email:

Occupation:

Employer:

Mother/Stepmother

Name:

Email:

Occupation:

Employer:

Section C: Request for Special Consideration based on Special Circumstances

1. Elementary/Secondary Tuition

If you will pay private elementary or secondary tuition in the 2023-24 school year for children in your household, please complete the following table. Specify both the school and grade for 2023-24 and the tuition costs and any assistance received for the 2022-23 year. You must provide a copy of your 2022-23 tuition bill as documentation* of this expense.

*All documentation must include the student's full name and Calvin ID number (if known) and may be sent to finaid@calvin.edu.

Student 1

Name

2023-24 Name of School

2023-24 Grade

2022-23 Tuition

Student 2

Name

2023-24 Name of School

2023-24 Grade

2022-23 Tuition

Student 3

Name

2023-24 Name of School

2023-24 Grade

2022-23 Tuition

Student 4

Name

2023-24 Name of School

2023-24 Grade

2022-23 Tuition

Total Tuition

Reductions to Tuition Charges (list any tuition assistance received from your church, school, grandparents, or any other family members or friends)

Subtract total reductions from total tuition

2. Reduction in Parental Income

If you have had a reduction in income of at least $10,000 since 2021 please explain in detail in the box below and complete the income projection questions. Please be specific, noting date of reduction and reason(s) for the reduction. You must submit documentation* of the income reduction (e.g. recent pay stubs, unemployment documents or letter of employment termination).

*All documentation must include the student's full name and Calvin ID number (if known) and may be sent to finaid@calvin.edu.

Explain below the reason(s) for reduction of income. (You may enter up to 1000 characters)

a. Father's projected 2023 earnings:

b. Mother's projected 2023 earnings:

c. Severance package, if applicable:

d. Projected unemployment compensation:

e. Other projected taxable income in 2023 such as interest, dividends, alimony received, capital gains/losses, etc.:

f. Adjusted Gross Income (sum of lines a-e):

g. Projected untaxed income in 2023 such as pension/IRA contributions or housing allowance received:

3. Other Extraordinary Expenses or Special Circumstances.

If you have other non-discretionary expenses or special circumstances (e.g. exceptional health care expenses, grandparent care expenses or higher than average cost of living expenses) please explain in detail below and provide documentation* (2 pages maximum) to substantiate the circumstances.

*All documentation must include the student's full name and Calvin ID number (if known) and may be sent to finaid@calvin.edu.

(You may enter up to 1000 characters)

4. Certification: We certify all information reported and submitted is true and accurate. We understand if this form or supporting documents are not submitted or submitted incomplete, the information may not be considered.

Yes, we certify the above to be true and accurate.

Contact Information