RETURN TO: Student Financial Aid Office
PO Box 45011 Lubbock, TX 79409-5011
Student Financial Center | West Hall 301
or email directly to: firstname.lastname@example.org
2021 Special Circumstance
Page 3 of 3
2020-2021 SPECIAL CIRCUMSTANCE REQUEST
Student Name: TTU R#:
Student Email: Phone #:
Parent(s) Email: Phone #:
Loss of Employment/Reduction of Income – REQUIRED DOCUMENTATION BELOW
Name of Person who lost job ___________________________
Relationship to Student ______________________________
Name of Previous Employer ___________________________
Last Date of Employment_____________________________
Severance Pay received?
Unemployment Benefits received?
Retirement Benefits being received?
Disability Benefits being received?
Will funds be taken out of your IRA, 401K, or other retirement
plan in order to supplement income or pay off debt
Has new employment been found?
Name of New Employer ______________________________
Letter from parent/student explaining circumstances surrounding the loss of income or reduction
Letter from previous employer stating last date of employment and year to date income OR
Copy of last pay check stub with year to date income information
Verification of severance pay
Verification of unemployment benefits
Verification of retirement benefits
Verification of disability benefits
Verification of funds taken out of retirement plan
Most recent pay check stub (if new employment has been found or if working multiple jobs)
Anticipated income for 2020 for employed parent(s)
I certify that the information contained on this form is correct. I understand that if I purposely give false or misleading information or forged signatures
on this form, I may be fined $20,000, sent to prison, or both; and it may result in the cancellation or repayment of all or part of my financial aid. I
understand that I must sign and return this form for my financial aid to be processed.
(Spouse signature is required except in cases of separation, divorce, or death).