2021-2022 APPEAL FOR EXTENUATING CIRCUMSTANCES
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.
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
o Social Security
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
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.
Office of Financial Aid
209 Maytum Hall
Fredonia, NY 14063
P: (716) 673-3253
F: (716) 673-3785