STATEMENT OF FINANCIAL NEEDS, RESOURCES AND AUTHORIZATION

STATEMENT OF FINANCIAL NEEDS, RESOURCES AND AUTHORIZATION
Michigan Department of Health and Human Services Michigan Rehabilitation Services
Student Name (Last, First, M.I.)
Student Name (Last, First, M.I Kartje Kristopher S
Social Security Number (last 4 digits)
Social Security Number (last 4 digits) 4388
Birth Date
MonthDayYear
Date
Name of School
Name of School Milan High School
Student Identification Number
Student Identification Number 2009858
Academic Year
MRS Counselor
Counselor Email Address
example@example.com
Counselor Email Address HouseT1@michigan.gov
Counselor Telephone Number 734-249-4514
Counselor Telephone Number
Counselor Fax Number 734-677-1128
Counselor Fax Number
Address
Counselor Address (Number and Street)
Street Address Line 2
CityState
Zip Code
Counselor Address (Number and Street) 3810 Packard Rd. Suite 170
PART A STUDENT: COMPLETE AND RETURN ALL COPIES TO MRS COUNSELOR
I authorize the Michigan Rehabilitation Services and an institutional representative of the above named school to exchange financial, academic and other information necessary to further my rehabilitation program.
Student Signature
Parent/Legal Guardian Signature (if minor)
Clear
Date
MonthDayYear
Date
PART B MRS COUNSELOR: COMPLETE AND FORWARD TO FINANCIAL AID OFFICE (Retain a copy in case file)
1. Period of support (Check ALL that apply)
FallWinterSpringSummer, or
Enter number of months
4. Estimated Special Support Costs for DisabilityRelated Services Equipment for the academic year to be provided by MRS, the student or family. (Enter the estimated amount or “0” if none
2. MRS will replace (Check ALL that apply)
Needbased loansWork Study
a. Disability Related Personal Equipment
3. Severity of disability precludes student contribution Earnings (Check ONE) Yes No
c. Personal Assistants or Attendants d. Special Transportation Costs e. Other (specify)
MRS Counselor's Signature
Clear
Contact Telephone Number
PART C FINANCIAL AID OFFICER: COMPLETE PER INSTRUCTIONS ON REVERSE SIDE AND RETURN TO MRS COUNSELOR
(Retain copy for school records)
1. Need analysis document (SAR) received
NoYes (if yes, complete below)
(Check ALL that apply)
Tuition/Fees
(Check ALL that apply)
Books/SuppliesRoom/BoardAmtTransportationMisc Personal ExpOther (specify)
a. Student Budget (for period noted in Part B)
b. Expected Family Contribution (EFC)
1) Pell Grant
2) Need Based Grants & Scholarships
3) Need based loans (or MRS replacement)
4) Work Study (or MRS replacement)
5) Other (specify includes Merit scholarship)
d. Total resources (including EFC)
(Check one)
3. Student has aid specifically for Tuition No Yes
e. Remaining unmet need
Amt
4. Need based loans (Perkins & Stafford)
Accepted – Gross AmountOffered – Gross AmountDeclined or Not Applied For
5. Comments
Financial Aid Administrator's Signature
Clear
Telephone Number
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
Counselor, please note: Instructions for Financial Aid Administrators, page 2, must be attached.
FINANCIAL AID ADMINISTRATOR’S INSTRUCTIONS FOR COMPLETING PART C
INFORMATION:
The purpose of the MRS6627, Statement of Financial Needs and Resources, and Authorization to Provide Services, is to coordinate assistance provided by your office and MRS in meeting student financial need including any special disabilityrelated expenses.
MRS customers are to be provided financial aid in the same manner as other students. MRS may supplement this assistance by helping with disabilityrelated costs, replacing Perkins or Subsidized Stafford Loans and WorkStudy awards when these are not appropriate for reasons related to the customer’s disability, and assisting with remaining financial need. MRS ASSISTANCE WILL NOT EXCEED THE STUDENT’S UNMET
INSTRUCTIONS:
Please complete Part C from your records as follows:
1.a. Enter the amount of student budget used in determining financial need and packaging aid for the student identified in Part A.
b.Enter the expected family/student contribution. Do not include an amount for summer savings i f box B3 is checked “yes.”
c.Enter the amount of financial aid awarded in each category. If none, enter “0.” Remember not to include scholarships solely based on academic achievement on line C2. Include academic scholarships on line C5 as “other.” If B2 is checked, enter the amount that would otherwise have been awarded for Need based Loans and/or Work Study. This is the figure MRS will use in providing replacement assistance. MRS generally will not replace more than $2500. Do not enter unsubsidized, Plus or alternative loans.
d.Total the resources available to the student and enter this amount.
e.Enter the student’s remaining financial need by taking the amount of the student budget and subtracting total resources. In addition, subtract any needbased loan if not already approved and accepted. See number 4 below.
2.Check the appropriate boxes to indicate the items included in the budget. If room and board is checked, enter the amount. This will allow MRS to properly plan with students who are receiving welfare or Social Security benefits.
3.Check the appropriate box to indicate whether the student is receiving aid specifically for tuition. If “yes” is checked, enter the amount. This will assure that any MRS assistance provided will not duplicate a tuition award.
4.Check the appropriate box in the Needbased Loan section to indicate the student’s status relative to these loans. IT IS ADVISABLE FOR STUDENTS NOT TO APPLY FOR A NEEDBASED LOAN UNTIL AFTER
MRS ASSISTANCE HAS BEEN DETERMINED.
5.Enter any additional comments, information, clarifications, etc. in the space provided. Indicate here if student is enrolled in a noneligible program or less than parttime and not eligible for financial aid.
Sign and date the form where indicated and return to the MRS counselor.
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STATEMENT OF FINANCIAL NEEDS, RESOURCES AND AUTHORIZATION

PART A STUDENT: COMPLETE AND RETURN ALL COPIES TO MRS COUNSELOR

PART B MRS COUNSELOR: COMPLETE AND FORWARD TO FINANCIAL AID OFFICE (Retain a copy in case file)

PART C FINANCIAL AID OFFICER: COMPLETE PER INSTRUCTIONS ON REVERSE SIDE AND RETURN TO MRS COUNSELOR

(Retain copy for school records)

FINANCIAL AID ADMINISTRATOR’S INSTRUCTIONS FOR COMPLETING PART C

INFORMATION:

INSTRUCTIONS: