WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE

SPECIAL CIRCUMSTANCES FORM - 2010-2011

Instructions: Use this form if your family's financial situation has recently changed due to any of the following:

1) loss of job or benefit
2) extended family support
3) elementary/secondary education
4) unusual medical/dental expenses
5) death in family
6) separation/divorce
7) marriage
8) increase in income/benefits
9) other

______________________________________________________________________
Student's Last Name                          First Name                                          Middle Initial

____________________________________     ____________________
Social Security Number                                         Class of

Complete all sections that apply to your circumstances.

I. INCOME CHANGES

1) Will your income and/or spouse's income be less in 2010 than in 2009 for any of the following reasons?
____ Yes ____ No

____ a) Unemployment/employment change
____ b) Divorce/separation
____ c) Death of spouse
____ d) Student/spouse disability
____ e) One-time income (e.g. inheritance, back SS pmts)

2) Please check the appropriate reason and explain, giving the date of the change in your situation.

DATE of change: _______________

3) If 2e is checked, identify income source & how funds are spent/invested.

4) If 2a, 2b, 2c or 2d are checked, complete the following information.

5) If you are divorced/separated, give only your information.

6) If the loss of income was due to the death of your spouse, give only your information.

II. UNUSUAL MEDICAL AND DENTAL EXPENSES

1) How much did you pay for medical/dental insurance in 2009?

(Do not include employer's contribution.) $_______________________

2) Total 2009 medical/dental expenses not paid by insurance. $_______________

3) Please explain if your unreimbursed medical/dental expenses will be lower, the same, or higher in 2010, and why. (Please attach explanation on separate sheet.)

4) From what sources will you finance these expenses? (Please attach a separate sheet.)

Proof of expenses and payment will be required for any adjustment.

III. EXTENDED FAMILY SUPPORT

1) Do you contribute financial support to relatives who are not members of your household?

____ Yes ____ No
If yes, complete the table below for each relative.

2) Explain if expenses will be lower, same or higher in 2010 and why? (Attach a separate sheet.)

3) From what sources will you finance this support? (Please attached a separate sheet.)

IV. ELEMENTARY/SECONDARY EDUCATION

1) Do you pay elementary/secondary education?

____ Yes ____ No If yes, provide written documentation and proof of payment.

V. OTHER

Please attach a separate sheet with explanation and documentation.

Certification: All information on this form is true and complete to the best of my knowledge. If asked, I agree to give proof of the information I have provided on this form.

_________________________________ ____________
Student's Signature                                           Date

_________________________________ ____________
Spouse's Signature                                             Date

After completion, please return along with appropriate documentation to:
WVSOM Financial Aid Office
400 North Lee Street
Lewisburg, WV 24901