SPECON
2019-20 SPECIAL CONDITIONS APPEAL
(2019-2020 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA400-Special Conditions Appeal 20181003
This form is accepted from July 1, 2019 – November 15, 2019 and from *February 1, 2020 June 30, 2020
.
*Students appealing for the 2019 calendar year and are submitting the appeal after November 15, 2019, must submit their
2019 Tax Return Transcripts and 2019 W-2’s for the Student / Parent / Spouse.
If your financial situation has changed since 2017, you may complete this form to request a FAFSA adjustment for the 2019-20
school year. You may request an adjustment to your income based on your 2018 actual earnings OR your 2019 estimated
earnings. The Financial Aid Office can help you determine which scenario will more accurately reflect your ability to pay for college.
Professional judgment evaluations are made on a case-by-case basis and do not guarantee eligibility for aid. Allow 10 business
days after the financial aid file has been verified for the appeal to be reviewed; if corrections are required during initial
verification, the process will be delayed.
All appeals must include the following documentation:
A s
igned and dated statement explaining your appealable situation from both parent(s) and student. Both must submit
their own signed statement with this completed form. Please be specific and include pertinent details (e.g. what has
changed, why the change occurred, and the dates changes occurred.) The specific details help us to better understand
your particular situation.
A copy of 2017 Tax Return Transcripts for the student/parent(s)/spouse if the Data Retrieval Option on the FAFSA was
not used.
Copies of all 2017 W-2’s for student/parent(s)/spouse.
Dependent / Independent Verification Form 2019-2020 (available at CCC website under Financial Aid Forms page)
In the table below, check the special circumstance that applies to you or your family situation.
Special
Circumstance
Dependent
Students
Independent
Students
Additional Required
Documentation
Reduction or loss
of employment or
untaxed benefits
Your parent(s’) or your
income earned in
2018 or 2019 is less
than that earned in
2017.
You (and/or your
spouse’s) income
earned in 2018 or
2019 is less than that
earned in 2017.
2018 W-2’s (Student /Parent/Spouse only if
appealing to use 2017 income
2018 Tax Return Transcriptonly if appealing to use
2018 income
Final or Most Current Paystub for Student/Parent/
Spouse with Year to Date Earnings
only if appealing
2019 income
Term
ination letter from employer (if applicable)
Unemployment Benefit Summary (if applicable)
Change in marital
status
Dat
e of Change:
Your parents were
married; separated;
divorced; or widowed
after the FAFSA was
filed.
You were married;
separated; divorced
or widowed after the
FAFSA was filed.
Provide documentation applicable to your situation:
Copy of Marriage Certificate
Copy of Divorce decree or legal separation
Proof of separate residence for both parties
Copy of Death Certificate (if applicable)
One time
payment
received
You or your parent(s)
received a one-time
payment (lump sum)
in 2017.
You (and your
spouse) received a
one-time payment
(lump sum) in 2017.
Write a statement and provided documents detailing
loss of one-time payment.
CCC ID# Last Name First Name MI
Mailing Address City State Zip Code
Telephone No. (include area code) Email Address
SPECON
2019-20 SPECIAL CONDITIONS APPEAL
(2019-2020 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA400-Special Conditions Appeal 20200414
Before an
adjustment can be made to your status, you must provide complete information regarding the change in 2017
financial circumstances for you, you and your spouse you and your parents. Please provide the actual amounts for 1/1/19
to 12/31/19 or the best possible estimates for 1/1/19 to 12/31/19. During the processing of this appeal, we may request
additional documentation from you, your spouse or your parent.
I am ask
ing for an adjustment to my FAFSA based on income/information from the:
2018You will list actual earnings received in 2018 from 2018 W-2’s and/or 2018 Tax Return Transcript.
2019You will list actual and estimated earnings received from January 1, 2019 December 31, 2019.
List Yearly Amounts Below
2018 or 2019 Taxable income Student Spouse Parent 1 Parent 2
Actual earned income from 1/1/19 - today
$
$
$
Estimated income from today 12/31/19
$
$
$
TOTAL earned and estimated
income for 2019
$
$
$
Unemployment Benefits
$
$
$
Business / Farm Income (Loss)
$
$
$
Veterans Non-Educational Benefits
$
$
$
Other Taxable Income (Severance pay,
Alimony, Capital Gains, etc.)
List Source:
$
$
$
Other Taxable Income (Severance pay,
Alimony, Capital Gains, etc.)
List Source:
$
$
$
2018 or 2019 Untaxed income Student Spouse Parent 1 Parent 2
Disability / Worker’s Compensation
$
$
$
Child Support Received
$
$
$
Other Non-Taxable Income
List Source:
$
$
$
Other Non-Taxable Income
List Source:
$
$
$
Requests will be denied if all required documentation is not submitted. Please ensure you have submitted all required
documentation with this appeal form.
I certify that information provided on this form is true and complete to the best of my knowledge. Purposely
giving false or misleading information may result in a delay or denial of my federal financial aid and I may be
fined up to $20,000, sent to prison or both. I hereby provide consent for the use of electronic records and
signatures on all financial aid documents. I understand that if I choose to sign electronically, my electronic
signature constitutes a binding contract and may not be denied legal effect, validity, or enforceability solely
because it is in electronic form or because an electronic signature or electronic record was used in its formation.
Student Signature and Date How do I create a digital signature with Adobe?
Parent Signature and Date (Required for Dependent Students)
Must be signed and mailed to CCC.
click to sign
signature
click to edit
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