Parental Request for
Reduced Income Consideration
for 2012-13 Academic Year
Arcadia University

You have indicated to us that your family income for the 2012 calendar year (January 2012-December 2012) will be reduced compared to your 2011 family income. In order for us to evaluate this situation and update your application to use your actual 2012 year family income, your parent(s) must fill out this form in its entirety. You may also complete this form online at --> Undergraduate Students --> Income Statement Forms.

Where projected income is requested, please estimate the information as accurately as possible since you will be required to verify the information at the end of 2012. If you get federal student aid based on incorrect information, you will have to pay it back. You may also have to pay fines and fees. If your student already received his/her financial aid package, you will be notified if any adjustment to the package can be made.

Please review your 2011 tax return prior to completing this form. Your projected 2012 income must be less than the income listed on the tax return to qualify for a reduction in income. When completing this form, please submit a copy of your 2011 federal tax return to Financial Aid Office if you have not done so already.

Below, please provide a brief description of the circumstances which caused/will cause the reduced income for 2012. Be specific and provide necessary details. No re-evaluation will take place if any information is left incomplete on the form.

Please note if you are selected for Federal Verification for the 2012-2013 year you must provide the University with all requested Verification documentation before this form can be reviewed.

All fields are required unless indicated.

Loss or reduction of income has begun or will begin: / (mm/yy)

List reason for income reduction below (if due to legal separation or divorce, provide date this occured and list financial information only of supporting parent (and spouse if remarried)on reverse side, regardless of whether joint tax return was filed. If separation or divorce occurred within the past 12 months, please attach legal document substantiating this.):

Student's First Name*
Student's Last Name*
Student's Social Security #
Parent (1) Name
Parent Email Address*
Household size for the 2012 calendar year
(including number of people parent(s) will support, including student)

Parent's Estimated Taxable Income for Year
(January 1, 2012 through December 31, 2012)

All fields are required. If answer is "0", enter "0"

Wages/Salaries/Tips (total amount) $
Interest $
Dividends $
Unemployment $
Business Income $
Rental Income $
Other (e.g. alimony, pensions, taxable Social Security Benefits, etc.). Indicate Source: $
Of the TOTAL AMOUNT listed above for Wages/Salaries/Tips, please indicate individual amounts for your mother and father. If applicable (include income for both parents, even if only one is experiencing a reduction in income.:
Mother's 2012 earnings $
Father's 2012 earnings (if applicable) $

Parent's Estimated Untaxed Income for Year
(January 1, 2012 through December 31, 2012)

All fields are required. If answer is "0", enter "0"

Social Security (untaxed portion only) $
Public Assistance (Welfare) $
Aid to families with Dependent Children (AFDC) $
Child Support Received $
Workman's Compensation $
Payment to tax-deferred pensions and savings plans $
Disability $
Veteran's Benefits $
Untaxed portions of IRA distributions $
Untaxed portions of pensions $
Tax exempt interest income $
Other (specify) $
(215) 572-2980 • FAX: (215) 572-4049 • • TITLE IV Code: 003235