Financial Aid Office
(708) 709-3735
Fax: (708) 709-3716
M:\StuServ\FAVAoffice\2014-15unusualenrollmenthistoryform.docx
2014-15 Unusual Enrollment History Form
Your 2014-2015 Free Application for Federal Student Aid (FAFSA) has been selected for ‘unusual enrollment
history’ review by the U.S. Department of Education because you have received the Federal Pell Grant at multiple
postsecondary institutions. This review will analyze your completed enrollment, earned academic credit, and
federal student aid paid .for the enrollment periods 2011-2012, 2012-2013, and 2013-2014. The outcome of this
review will determine your 2014-2015 eligibility for federal student aid at Prairie State College. Please complete
this form and submit it to the Prairie State College Office of Financial Aid.
___________________________________________________ ________________________________
Student’s Last Name First Name Middle/Maiden Name
____________________________ ________________________ _________________________
ID Number Social Security Number Date of Birth
___________________________________________________ ________________________________
Address (include apartment number) Phone number (include area code)
___________________________________________________ ________________________________
City State Zip Email Address
COLLEGE AND UNIVERSITIES ATTENDED
Please list all institutions attended during the enrollment periods 2011-2012, 2012-2013, and 2013-2014. Attach an
unofficial transcript from each of the institutions attended AND attach a statement of explanation for any course
for which you failed or withdrew from. Attach any additional documentation that supports circumstances that
affected course completion or course withdrawal (i.e., medical bills/hospital records, military assignment, or court
documentation of legal events). Additional information may be requested.
Name of College/University
Federal Student Aid Received
STUDENT CERTIFICATION AND SIGNATURE
The U.S. Secretary of Education has the authority to verify information reported on federal student aid
applications. By signing this document you certify that the information you have provided is true and
complete to the best of your knowledge, under penalty of fine, imprisonment, or both if you purposely
provide false or misleading information.
_________________________________________ _______________________________________
Student Date
