2019-2020 APPEAL FORM FOR SPECIAL CIRCUMSTANCES
Peralta Student ID:
Student Full Name
All students requesting special circumstances consideration will be verified; tax transcripts and other documents pertaining to the
circumstances are required.
Submitting an appeal for special circumstances does not guarantee an adjustment will be
made to your aid
package. Decisions are final and will be communicated directly to the student via e-mail.
Section A- Explanation of Special Circumstances
- You
must attach
a written statement detailing the specifics of your
circumstances and provide any pertinent information that will help us better understand your particular situation. Make sure to
date and sign your written statement. If you are a dependent student, your parent must also date and sign the statement.
Section B - Special Circumstances for Consideration -
Please review and indicate which special circumstance applies to you.
Complete copies of documentation listed as
required (*)
must be submitted along with this form to review your request.
Additional documentation that helps support your appeal, even if not listed as required, can be submitted as well.
List your
name and Peralta ID number at the top of all submitted documents.
For an Independent
Student
Student or parent(s)'
income earned in 2018 or
2019 will be less than what
was earned in 2017.
Your (and/or your spouse's)
income earned in 2018 or
2019 will be less than what
was earned in 2017.
*
2017 US Federal IRS Tax Transcript
*
W-2 Wage statements
*
Unemployment Award Letter
*
Last pay stub showing year-to-date earnings
*
Termination notice from employer
Other Loss of
Income
or
Extraordinary
Expenses
•
Alimony
• Child Support
•
Retirement/Pension
•
Social Security (taxed)
• Workers'
Compensation
•
Medical/Dental
• You or your parent(s)'
received benefits in 2017
which have ceased or been
reduced in 2018 or 2019.
• You or your parent(s)'
paid expenses not
covered by insurance and
are over the expected
cost of attendance.
• You (and/or your spouse)
received benefits in 2017
which have ceased or been
reduced in 2018 or 2019.
• You (and/or your spouse)
paid expenses not covered by
insurance and are over the
expected cost of attendance.
*
2017 US Federal IRS Tax Transcript
*
W-2 Wage statements
*
Original 2017 Benefit statement listing
total amount received
*
Revised 2018 or 2019 Benefit
statement and/or court documents
listing updated amount to receive and
effective date
and/or
*
Insurance coverage
*
All medical bills
Your parents separated or
divorced AFTER filing the
FAFSA.
You and your spouse
separated or divorced
AFTER filing the FAFSA.
* 2017 US Federal IRS Tax Transcript
* W-2 Wage statements
* Divorce decree or separation agreement or
proof of separate addresses
Death of a Parent
or
Spouse
A parent has died AFTER
filing the FAFSA.
Your spouse has died AFTER
filing the FAFSA.
*
2017 US Federal IRS Tax Transcript
*
W-2 Wage statements
*
Death certificate
One-time
Payment
Received
Your parents received a
one-time lump sum
payment of monies in
2017.
You (and your spouse)
received a one-time lump
sum payment of monies in
2017.
* W-2 Wage statements
* 2017 US Federal IRS Tax Transcript
* Documents detailing One Time Payment
amount, source, reason
