Professional Judgement

If you and your family have experienced unusual financial circumstances, complete this form to the best of your ability and provide the requested documentation to our office. We will review your request and respond as quickly as possible, but please allow several weeks for processing. This is not an all-inclusive list. If you have experienced a hardship that is not listed here, provide us with as much detail as possible on how the situation has affected you financially, either in terms of income loss or additional expenses. If we make changes to your financial aid, your financial aid award information will be updated in the financial aid section of your Faulkner account.

Please complete Part A and Part F of this form as well as any other sections for which you wish to document unusual circumstances. You may skip sections that do not pertain to you.

Part A: Application Information and Verification Form Status

Before your special circumstances can be considered in the processing of your financial aid you must first submit a VERIFICATION FORM and tax documentation to verify the accuracy of all financial data and other information you listed on the Free Application for Federal Student Aid (FAFSA). When necessary, as a result of this process, our office will update your FAFSA to more accurately reflect your current financial situation. Please note that, if you made an error on the FAFSA you previously submitted, Faulkner University must correct that information (even if unrelated to your special circumstances request), and as a result your eligibility for federal aid may actually decrease!

Student Name*

First Middle Last

Student ID#*

In order to file the Verification Form and the appropriate tax documentation must be submitted*

I have attached a 2024-2025 Verification Form and copies of signed federal 2022 tax returns for all filing members of the household
The 2024-2025 Verification Form and tax documentation was already submitted.

Verification Form and/or Tax Documentation

Drop files here or

Max. file size: 64 MB, Max. files: 5.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

Part B: Private School Tuition of Child Care/Dependent Care Expenses

Note: Adjustments for K-12 private school tuition for younger siblings is allowed.List the family member and the amount of relevant expenses for each

Name of Family Member	Age	Relationship to Student	Amount	Type of Expense

Please explain if these expenses will be lower, the same, or higher in 2024 and why:

Upload receipts for tuition payments or child care/dependent care expenses itemized statement of expenses 2023 and projected expenses for 2024, or submit them to the Financial aid office.

I will submit the documents to the Financial Aid office
I will upload the documents here

2023 receipts for tuition payments or child care/dependent care expenses.

Max. file size: 64 MB.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

Signed itemized statement of expenses for 2023 and projected 2024 expenses.

Max. file size: 64 MB.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

Part B: Unusual Medical and Dental Expenses

Amount paid for medical/dental insurance in 2023. Do NOT include employer’s contribution

Amount paid for medical/dental expenses in 2023 NOT COVERED BY INSURANCE:

Part C: Unusual Medical and Dental Expenses Continued

Will your non-reimbursed medical/dental expenses be lower, the same, or higher in 2023 and why?

Submit the necessary forms

I will submit these documents to the Financial Aid office
I will upload these documents here

Please attach a copy of the following:

Your 2022 Federal Income Tax Form, schedule A -Itemized Deduction

Your Receipts of medical and dental payments from year 2023

2022 Federal Income Tax Form, Schedule A – Itemized Deduction.

Max. file size: 64 MB.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

Receipts of medical and dental payments from year 2023, and signature (below) of person for which medical information is being disclosed.

Max. file size: 64 MB.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

Signature

I hereby authorize the use or disclosure of my individually identifiable health information to Faulkner University as described above and as described in documentation that I have voluntarily submitted. Information disclosed to Faulkner University is limited to health care claims or receipts for the period of time beginning January 1, 2023 and ending December 31, 2023. This information is being disclosed to Faulkner University for the sole purpose of documenting special circumstances. This authorization to use these records will expire one year from the date signed below unless I indicate a shorter period. At any time, I have the right to revoke this authorization prior to its expiration date by notifying Faulkner University in writing, but the revocation will not have any effect on any actions Faulkner University took before it received the revocation. I also have the right to see and copy the information described on this form if I request it. I further understand that I am not required to sign this form to receive any services from Faulkner University

Length of Autorization

I wish to give Faulkner my authorization for one year
I wish to give Faulkner my authorization for less than one year

I wish to give Faulkner my authorization until:

Name of Patient

First Middle Last

By entering your name and checking the box you are agreeing to disclose the provided health information

Signature

I have read and agree to the above statement and verify that I am the patient whose name appears on this form

Part D: Income Reduction

If your income and/or your spouse’s or parents’ income will be less in 2023 than it was in 2022, check the appropriate reason and explain the situation below.

Unemployment or Change in Employment
Divorce or Seperation
Third Choice
Disability of Student, Spouse, or Parent
Death of Parent or Spouse
Natural Disaster
Loss of Untaxed or Income Benefit
One Time Income-Inheritance, Moving Expense Allowance, IRA or Pension Distribution

EXPLANATION of your situation, including dates of the change in your situation:

If you or your parents are divorced or separated, give only your information or the information of the custodial parent. If the loss of income was due to the death of your spouse or parent, give only your information of the information of your surviving parent.

Anticipated Family Income

Relationship	Wages, Salaries, Tips, Severance Pay, Unemployment, Disability Pay	Other Taxable Income (rentals, pensions, etc. as reflected on your tax return)	ADC/AFDC (Annual est.)	Child Support Received (Annual est.)	Other Untaxed Income (Social Security, housing, etc.)

Fill out the fields that pertain to you. For Relationship enter Student first, then Father, Mother, Spouse, etc. as they apply. If you or your parents are divorced or separated, give only your information or the information of the custodial parent. If the loss of income was due to the death of your spouse or parent, give only your information of the information of your surviving parent

Statements documenting estimated earnings or verification of actual Social Security, unemployment benefits, workers’ compensation benefits, or disability payments are needed.

I will submit these to the Financial Aid office
I will upload these here

Documents of estimated earnings

Drop files here or

Max. file size: 64 MB, Max. files: 5.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

If you or some whose income you rely on is an ordained Minister, the 2023 Federal Income Tax Form, Schedule C documentation is needed

I will submit this to the Financial Aid office
I will upload this here
Does not apply

2023 Federal Tax Form, Schedule C

Max. file size: 64 MB.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

Part E: Unusual Debts

Use this section to address high debt payments that were a result of unusual circumstances, such as credit card debts to cover unemployment expenses or failed business; legal fees for divorce, adoption, etc; education loans of parents or spouses; or personal debts for non-discretionary expenses. Please do not include normal debt expenses such as a mortgage.

List the type and purpose of the debt, total amount owed, and amount of monthly payments:

Type or Cause of Debt	Monthly Payment	Original Debt	Amount Owed

Please explain if these expenses will be lower, higher, or the same in 2024 and why.

Documentation concerning contract; billing or payment summary from the individual, company, or agency to which the money is owed.

I will submit this to the Financial Aid office
I will upload this here

Debt Documents

Max. file size: 64 MB.

Note: The maximum file size supported is 2MB. File Types Supported: .pdf, .doc, .docx, .jpeg, .jpg, .png

Part F: Certification

Signature

I agree that the information provided on this form is true and correct to the best of my/our knowledge, and that I understand that knowingly giving false information will result in a review of my financial aid eligibility, and that I am the person whose name appears on the form.

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Introduction

Part A: Application Information and Verification Form Status

Part B: Private School Tuition of Child Care/Dependent Care Expenses

Part C: Unusual Medical and Dental Expenses Continued

Part D: Income Reduction

Part E: Unusual Debts

Part F: Certification