Last Name _________________________ First Name F#______________________
If you believe you have experienced a significant loss in income, an adjustment to your 2021-2022 FAFSA maybe be possible. This form only
deals with federal aid; it cannot be used to alter eligibility for state aid programs like TAP, SUNY Tuition Credit, or Excelsior. If your current
EFC is zero, then you will not be eligible for this appeal.
DOCUMENTATION: All applications MUST include the following items.
o The reason for your appeal must be specified on the page #2. Including a statement explaining in what way the circumstance has
altered your financial situation.
o 2019 Federal Tax Return (First 2 pages only) or Tax Return Transcript
o 2019 W-2 Earnings Statements.
o The additional documentation as listen below.
Extenuating Circumstances
Required Supporting Documentation
Loss of Employment: Job, benefits, or both have been lost, or
earnings are now less in a newly acquired job. Only a significant
income reduction may affect the financial aid offered.
Last pay stub showing year to date earnings.
Termination notice from employer showing last date of
Unemployment statement showing amount received,
benefit beginning and end dates.
Loss of an Untaxed Income: This may include the loss of one of
the following.
o Retirement/Pension
o Social Security
Workers Compensation
Original 2019 benefit statement listing the total amount
Revised benefit statement listing updated amount
received and effective date.
Documentation of the loss of support.
Separation or Divorce: Separation or divorce AFTER filing the
FAFSA, but no later than 12/31/2021. Also, parties that are still
living in the same household will not be considered.
Divorce Decree or Separation Agreement.
Proof of separate residences.
Child Support or Alimony being received.
Death of Parent or Spouse: Your parent or spouse has passed
away since filing your FAFSA.
Copy of death certificate
W-2 of the deceased
Medical/Dental Expenses NOT covered by Insurance: Out of
pocket medical or dental expenses paid in 2019 (Tax year) or 2021
(Current year) beyond the amount already factored into the federal
EFC formula. Costs paid by insurance or someone else cannot be
Copy of schedule A- itemized deductions from your
federal tax return OR proof of out of pocket medical,
dental, or eye care payments.
Letter from insurance company showing medical and
dental expenses not covered by insurance.
One-Time taxable income used for a life changing event: IRA,
Pension Distribution, Back-Year child support, etc.
Copy of statement showing payments received.
Verification of use of funds. Payments toward consumer
debt will not be considered.
Why income cannot be used for educational expenses.
Return this form to:
Office of Financial Aid
209 Maytum Hall
Fredonia, NY 14063
P: (716) 673-3253
F: (716) 673-3785
Please only select one. Provide a statement
detailing how the circumstances selected have impacted your financial situation.
Medical or dental expenses not covered by insurance.
One-time taxable income used for life changing even.
Loss of untaxed income. Date of change:
Separation or Divorce. Date of separation/divorce:
Death of Parent or Spouse. Date of death:
Loss of Employment. Last date of employment:
Complete this section only if your appeal is related to a loss of employment.
I certify that all information provide in this document is true, complete and accurate to the best of my knowledge. I further understand that any false
statements or misrepresentation will be cause for denial, reduction, withdrawal, and/or repayment of financial aid. Also, purposely giving false or
misleading information on this worksheet may lead to fines, jail time, or both. I authorize the State University of New York at Fredonia to make any
change(s) necessary as a result of the updated information that I have provided.
Student Signature: Date: Parent Signature: Date:
Expected Income Type
Income to Date
(1/1/21 – Today)
Estimated Income
(Tomorrow – 12/31/21)
Expected income of Parent #1
$: $: $:
Expected income of Parent #2
$: $: $:
Expected income earned by Student
$: $: $:
Expected income earned by Spouse
(Married, Independent students)
$: $: $:
Severance Package
$: $: $:
Other taxable income: (Dividends, interest,
pensions, annuities, alimony, unemployment
compensation, capital gains, etc.)
$: $: $:
Social Security Benefits
$: $: $:
Child Support Received
$: $: $:
Other untaxed Income: Pre-Tax pension
contributions, interest or dividends,
worker’s compensation, IRA, Keogh,
Money received or paid on your behalf
$: $: $:
Child Support Paid
$: $: $:
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