UNUSUAL ENROLLMENT HISTORY
Your 2019-2020 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 Federal Pell Grants and/or Loans at multiple postsecondary institutions. This review will
analyze your completed enrollment, earned academic credit, and federal student aid paid for the enrollment periods 2015-2016, 2016-2017,
2017-2018 and 2018-2019. The outcome of this review will determine your 2019-2020 eligibility for federal student aid at Polytechnic University.
If a conflict code (C-code) of 359 (UEH Flag 2) or 360 (UEH Flag 3) exists on your FAFSA, you will be required to complete this form and
provide documentation for your unusual enrollment history. Once received, the Financial Aid Office will review your documentation and contact
you if anything further is needed.
INDICATE THE REASON(S) FOR YOUR UNUSUAL ENROLLMENT HISTORY
During the 2015-2016, 2016-2017, 2017-2018 and/or 2018-2019 award year, you or a member of your household:
suffered from severe illness
had a major family emergency had a military obligation
had to change your address
Student had academic credit earned at each of the previously attended institutions - No further action required.
If this item is selected, the student is required to submit a statement of explanation regarding his/her situation on those
transcripts were no credits were attained. Also, other third party documents will be required.
I CERTIFY ALL INFORMATION ON THIS FORM IS TRUE AND ACCURATE. I HAVE PROVIDED COMPLETE INFORMATION TO
THE BEST OF MY ABILITY.
Student Signature: ______________________________________________________________ Date: __________________________
Officer Signature: _______________________________________________________________
Colleges and Universities Attended
Please list all institutions attended during the enrollment periods 2015-2016, 2016-2017, 2017-2018 and 2018-2019. Attach an official
transcript from each of the institutions attended. Additional information may be requested.
Name of University/College
Academic Year Attended Federal Aid Received? Transcript Attached?
Last Name First Name ID Number Email
City State Zip code