Fillable 2020-2021 Special Conditions Appeal Form (Clark State Community College)

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2020-2021 Special Conditions Appeal Form (Clark State Community College)

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Financial Aid
1
2020-2021
Special Conditions Appeal Form
Financial aid for the 2020-2021 award year is based on 2018 income. If you and/or your family have
had a significant change in your financial situation during 2019 or 2020, you may request to have
your financial aid re-evaluated. This review will be based upon the information provided through a
process called Special Conditions Review.
SECTION A: STUDENT INFORMATION
Name____________________________________________ Student ID Number___________________
Address _____________________________________________________________________________
Street City State Zip
Primary Phone __________________________________
SECTION B: APPEALABLE CIRCUMSTANCES
Appealable circumstances include:
• Loss of earnings in 2019 or 2020 due to a loss of job, change in hours or reduction in pay
• Loss of untaxed income or benefits in 2019 or 2020 such as child support received
• Loss of taxed income in 2019 or 2020 such as alimony
• Loss of income due to separation or divorce after FAFSA application was submitted
• Loss of one lump sum payment received in 2019 or 2020 such as severance pay or withdrawal from
a retirement program
• Payment of medical or dental expenses not covered by health insurance
• Death of a spouse/parent after FAFSA application was submitted
• Payment of elementary/secondary school expenses for tuition
If you and/or your family meet one of the criteria listed above or if you have another extenuating
circumstance that we should consider, please complete this application and submit it with the required
documentation. Additional documentation may be requested after your application is reviewed. It is
important for you to turn in ALL requested documentation as outlined on this form. If you do not provide
all required documentation, then your application may be delayed or denied and returned to you.
SECTION C: APPLICATION PROCESS
Before you submit this application, please review and complete the following steps:
1. You (the student) submit the 2020-2021 FAFSA.
2. As part of the special conditions application, the student will be selected for verification. You and
your parent (if applicable) must complete the 2020-2021 Verification worksheet and submit it to
our oce along with copies of the 2018 IRS Tax Transcripts (must request this transcript from the
IRS website) for you and your parent(s). If you are married and your spouse filed separate, we will
need a copy of your spouse’s 2018 Federal Tax Transcript. We will not require the tax transcripts if
you opted to transfer your IRS data to your FAFSA application.
3. You must be currently enrolled at the time we process the Special Conditions Application.
Financial Aid
FAC20PJ
Financial Aid
2
4. You have completed the Special Conditions Application and have attached all required
documentation for the circumstance being considered. Again, failure to provide the required
documents will delay the process.
The application process can take up to 6 weeks. Once the application is processed, you will receive
notification of the results by email. If the revisions result in additional federal aid eligibility, you will
also receive a revised award notification email.
SECTION D: REASON FOR APPEAL
Examples for special conditions appeal
• A significant reduction in earnings.
• Death of a spouse or parent.
• Separation or divorce.
• Disability.
• One-time income such as severance pay, etc.
• End of benefits (unemployment, child support, etc.).
• Unusual medical expenses paid by student, spouse, or parent.
This is not a complete list. If you think you have cause for a special conditions appeal, contact the
Financial Aid Oce.
NOTE: If your Expected Family Contribution (EFC) is 0, you cannot qualify for a special condition
appeal.
Personal Statement (Required)
Please explain the circumstances that changed. Attach a separate sheet of paper if necessary.
Certification Statement
I certify that all of the information on this form and accompanying documents are true and complete
to the best of my knowledge. Furthermore, I affirm that I have not knowingly or intentionally provided
any false or fraudulent documentation.
Student Signature ___________________________________________ Date____________
Parent Signature (if parent information is provided) ________________________ Date____________
937.328.6034 | financialaid@clarkstate.edu | 570 East Leel Lane, Spring ield, Ohio 45505
Financial Aid
3
SECTION D: REQUIRED DOCUMENTS
Loss of earnings in 2019 or 2020 due to:
• Required reduction in hours or rate of pay
• Unemployment
• Job relocation
• Disability
• Letter from each of your prior employers
stating the last date of employment (must be
on letterhead)
• Copy of your last paystub and if applicable,
your spouse’s last paystub showing year-to-
date earnings in 2019
• Copy of your unemployment eligibility
determination notice. Also include a copy
of your extended unemployment benefits if
applicable
• Information about a severance package if
applicable
• Disability amount approved and eective
date if applicable
Loss of income in 2019 or 2020 due to change in
family status:
• Separation/divorce
• Death of a spouse/parent
Copy of federal tax return, W2 statements for
each taxpayer:
• For separation, verification of separate
addresses and any temporary income such as
spousal support or child support
• For divorce, divorce decree and
documentation of spousal and/or child
support
• For death of parent/spouse, copy of death
certificate
Loss of untaxed income:
• Child support
• Workers Compensation
• Court or agency documentation stating
termination date of benefits
• Documentation showing amount received in
year appealed
One time income or lump payment:
• Severance
• Retirement payout (not rollover)
• Insurance settlement
• Explanation of why the funds were withdrawn
• Copies of receipts for loans/expenses paid
using the lump sum payment (this cannot
include normal monthly expenses)
Unusual medical expenses paid by student/
parent not covered by health insurance
Copies of medical bills documenting payment
made by you and/or your parent in 2019 or 2020
not covered by health insurance. Certain limits
apply.
_____________________________________________________________________________________
FOR OFFICE USE ONLY
Appeal approved? Yes No Updates to transaction #_________
Updates:__________________________________________________________ Revised EFC:_______
Financial Aid Oce Signature____________________________________ Date__________________
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2020-2021 Special Conditions Appeal Form (Clark State Community College)

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Completed 26 July 2020

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