Fillable 2019-2020 COVID-19 Special Circumstances Appeal Form (Lehigh Carbon Community College)

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2019-2020 COVID-19 Special Circumstances Appeal Form (Lehigh Carbon Community College)

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The 2019-2020 COVID-19 Special Circumstances Appeal Form (Lehigh Carbon Community College) form is 2 pages long and contains:

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  • 4 check-boxes
  • 52 other fields

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File type: PDF

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OFFICE OF FINANCIAL AID
4525 Education Park Drive, Schnecksville, PA 18078
P 610.799.1133 | F 610.799.1798
E finaid@mymail.lccc.edu
OFFICE USE ONLY: 19CVSC
2019-2020
COVID-19 Special Circumstances Appeal Form
Student Name Student ID
Purpose
The 2019-20 FAFSA takes into account 2017 tax year income. If your family’s current financial situation has been
drastically affected by the COVID-19 Pandemic, you may wish to consider submitting this form. Upon review, the
Financial Aid Office may deem it appropriate for your FAFSA information to be adjusted to be more equitable and
representative of your current financial situation.
Instructions
Complete sections 1 through 3 and ALL required steps below.
Deadline
For the 2019-20 academic year, the deadline for consideration is June 30, 2020.
1. SPECIAL CONDITION(S)
Indicate the appropriate reason(s) and the date(s) of your family's change in circumstance by checking the box(es)
below. You will need to attach the required supporting documentation indicated below the applicable circumstance(s).
Loss of employment or change in employment due to COVID-19
• Letter from employer on company letterhead that includes the last date of employment.
• Unemployment benefits determination document.
• Documentation of year-to-date income.
Month/Day/Year
Temporary reduction in income due to COVID-19
• Letter from employer on company letterhead that includes the last date of employment.
• Unemployment benefits determination document.
• Documentation of year-to-date income
Month/Day/Year
Loss of 2020 earnings due to disability or natural disaster
• Documentation of disability determination.
• Documentation of natural disaster.
• Documentation of year-to-date income (copies of most recent pay stubs from all employers).
• Documentation of year-to-date income
Month/Day/Year
Other
Provide a detailed explanation and attach documentation for the circumstance(s) impacting the reduction in your
2020 family income as compared to your 2017 income. If additional space is needed, attach a separate sheet.
-2-
OFFICE USE ONLY: 19CVSC PERM22-t (AC) 4/16/20
2. STATEMENT OF ESTIMATED 2020 INCOME
Estimate your family income for the entire year (January 1, 2020 to December 31, 2020) by indicating the annual
amounts in each space below. If the question does not apply to you, indicate ‘0’ - do not leave any lines blank.
This form will be returned to you if it is incomplete, and this will delay the processing of your financial aid.
If the student is Dependent, list parent(s) and/or student’s information.
If the student is Independent, list student’s and/or spouse’s (if applicable) information.
Dependent Student’s Dependent or Independent
Parent(s) Information &/OR Student/Spouse’s Information
A. Expected 2020 Taxable Income
1. Wages, Salaries, Tips Father $ Student $
Mother $ Spouse $
2. Pension & Annuities $ $
3. Interest/Dividend Income $ $
4. Business or Farm Income $ $
5. Capital Gains $ $
6. Rents Which Will Be Received $ $
7. Alimony $ $
8. Unemployment Compensation $ $
9. Other Taxed Income, $ $
Explain:
B. Expected 2020 Untaxed Income & Benefits
1. Social Security $ $
2. Public Assistance $ $
3. Child Support $ $
4. Housing Allowance $ $
5. Retirement or Disability Benefits $ $
6. Worker's Compensation $ $
7. Payments to Tax-Deferred Pensions $ $
& Savings Plans (Paid directly or withheld
from earnings - include 401K & 403B plans)
8. Untaxed Portion of Pension $ $
9. Other Untaxed Income, $ $
Explain:
Total: $ Total: $
3. SIGNATURE(S)
By signing below, I/We certify that the above information is true and correct to the best of my/our knowledge:
Student Signature Date Student Daytime Phone Number
If Dependent, Parent Signature Date If Independent & Applicable, Spouse’s Signature Date
Ensure that Sections 1 and 2, are complete and that all of the required supporting documentation is attached
and return this form in person, via mail, fax, or email to finaid@mymail.lccc.edu
at your earliest convenience.
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2019-2020 COVID-19 Special Circumstances Appeal Form (Lehigh Carbon Community College)

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Completed 4 October 2020

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