Financial Aid
937.328.6034 | | 570 East Leel Lane, Springfield, Ohio 45505
Unusual Enrollment History
The U.S. Department of Education has established regulations to prevent fraud and abuse in the
Federal Student Aid program by identifying students with unusual enrollment histories. Some
students who have an unusual enrollment history have legitimate reasons for their enrollment
at multiple institutions. However, such an enrollment history requires our oce to review your
file in order to determine future federal financial aid eligibility. If selected by the Department of
Education, this must be resolved before you will receive financial aid.
SECTION A: Student Information
Name____________________________________________ Student ID Number___________________
Street City State Zip
Home Phone __________________________________ Work Phone _____________________________
SECTION B: Schools Attended
Processing for Unusual Enrollment History cannot begin until a completed form and all academic
transcripts (if applicable) are received.
Please list all colleges attended during the time frame listed below, including the Clark State
Community College. If you attended multiple schools during the indicated time frame, attach an
additional page listing all schools you attended and include your name and Student ID at the top of
each page. If you have attended Clark State Community College during any of these years, you are
required to list Clark State Community College.
You must attach an academic transcript (ocial or unocial) from each college attended. Please
note: if any unocial transcripts are unclear you will be required to provide ocial academic
transcripts. Failure to report all colleges with attached transcripts will result in denial of your
request for financial aid at Clark State Community College.
Name of College Dates Attended Did you earn credit hours?
Yes No
Yes No
Yes No
Yes No
Financial Aid
Financial Aid
937.328.6034 | | 570 East Leel Lane, Springfield, Ohio 45505
SECTION C: Extenuating Circumstances
If personal reasons explain your failure to earn academic credit, provide a written statement that
explains your situation and include supporting documentation.
SECTION D: 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_______________________
For oce use only
FA Sta decision ________________________________________________________________
Signature of authorized school ocial ________________________________ Date __________