FINANCIAL AID OFFICE
Financial Aid Office * 96-045 Ala Ike Street * Pearl City, 96782
Phone: 808 455-0606 * Fax: 808 453-6371 * Website: www.leeward.hawaii.edu/finaid * MyUH Services: https://myuh.hawaii.edu
Rev: 04/2020
2019-2020 Appeal for Special Circumstance
________________________ ________________________ _____________________ _________________
Last Name First Name UH ID/Username Phone Number
You may complete this form/process if the income information you reported on your 2019-2020 Free Application for Federal
Student Aid (FAFSA) does not reflect your/your family’s current financial situation due to an extenuating circumstance (i.e., loss
of employment, divorce, etc.). We will consider your appeal based on the documentation you provide.
1) Submit the verification documents listed below. By completing this appeal, you are selecting yourself for a process
called verification. If you start the verification process, you will need to complete it, regardless if you withdraw or
cancel your appeal. If you do not finish the verification process, any financial aid that you have been paid will need to
be completely returned.
a. 2019-2020 Verification Worksheet
b. DEPENDENT Students – 2017 IRS Tax Return Transcripts for student and parents*
c. INDEPENDENT Students – 2017 IRS Tax Return Transcripts for student and spouse (if married)*
*IRS Tax Return Transcripts must be submitted even if the IRS Data Retrieval was utilized.
2) Submit a detailed statement that explains how and why your/spouse or parent(s) income in the 2019-2020 academic
year has changed since the 2017 calendar year.
a. Please indicate who the special circumstance applies to: Self Spouse Parent(s)
3) Complete the table below for the person you selected above (who the special circumstance applies to):
Income Table (provide estimates if completing prior to July 1)
Entire Period from July 1, 2019 - June 30, 2020
Gross income earned from work
Other taxable income (interest income, unemployment etc.)
Other untaxed income (workers comp, untaxed pensions, etc.)
4) Indicate the type of circumstance and provide the respective documentation to support the circumstance:
Unemployment Insurance Determination of Insured Status Letter OR
Online Unemployment Insurance Summary of Claims
At least 3 months of recent pay stubs or other documents reflecting actual
wages and/or hours for you/spouse or parent(s)
Legal documentation from a government agency or lawyer to show divorce or
separation AND W-2’s for both parties
Death of a spouse or
parent
Death certificate or obituary AND W-2’s for the deceased party
Any pertinent documentation to support your circumstance
I certify that the information I attached is accurate and true to the best of my knowledge. Electronic signature(s) or digital
signature(s) will NOT be accepted.
Student Signature: _________________________________________ Date: __________________
Parent Signature: __________________________________________ (Dependent Students only) Date: __________________
University of Hawai'i institutions do not discriminate on the bases of age, race, sex, color, national origin, or disability in its programs and
activities. For more information or inquiries regarding these policies, please contact the individual campus Title IX Coordinator. UH Title IX
Coordinators' names and contact information are available at: https://www.hawaii.edu/titleix/help/coordinator/
