Fillable Appeal Form 17-18

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Appeal Form 17-18

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Special Circumstance Appeal Form
2017-2018
The University of Dayton strives to offer our families the best financial aid packages possible within the limitations of federal, state and
university funding levels. We understand that the FAFSA does not always capture the current financial snapshot of your household and
that certain circumstances may present your family with unique financial challenges. By completing this form, we will be able to
determine if these factors have any effect on your 2017-2018 expected family contribution (EFC), which in turn affects your need.
Instructions
Please complete this form in its entirety. Please provide documentation which supports your reason for your appeal and include the student’s
name and student ID number on all documents to insure proper identification. In addition, we must have the results of your 2017-2018 Free
Application for Federal Student Aid (FAFSA) on file in order to review this form. This can be filed online at http://www.fafsa.gov. If your
FAFSA is selected for federal verification, you must complete that process before your special circumstance appeal form can be reviewed.
Your appeal will be evaluated by the Financial Aid staff within a timely manner based on the volume received. Please allow up to four (4)
weeks for review during peak processing (February through June). For your convenience, you can email, mail or fax the documentation
to us. If you need assistance in completing this form, please contact us.
Student Information
Last Name: First Name: MI:
Address:
City: State: Zip:
Home Phone Number: Cell Phone Number:
UD Student ID number: Social Security Number:
Your grade level for the 2017-2018 academic year:
First year Sophomore Junior Senior
Reason(s) For Appeal
Involuntary loss of income/benefits:
(due to unemployment, loss of overtime, loss of non-recurring income/benefits, death of wage earner, divorce,
separation, loss of child support received, etc.)
Date loss of income/benefit took affect: ______/______/_______
Please attach letter from employer, unemployment statement, most recent pay stub(s), etc.
Yes No
Unreimbursed medical/dental expenses:
Amount paid in 2017: $ __________ ____ __ .00
Please attach copies of year-to-date payment statement(s), 1040 Schedule A (if applicable), etc.
Yes No
Other:
(unreimbursed expenses for elder care of loved one, adult child not living in household, funeral expenses, etc.)
$ __________ ____ __ .00
$ __________ ____ __ .00
$ __________ ____ __ .00
Please attach copies of supporting documentation
Yes No
Continued on next page
UD ID #:
Name:
Briefly explain your reason for requesting additional financial aid and provide supporting documentation:
Estimated 2017 Income: REQUIRED
Since the 2017-2018 FAFSA uses the 2015 tax year figures, please provide all ANTICIPATED income sources from
January 1, 2017 to December 31, 2017. Provide copies of most recent pay stub for all wage earners listed below.
Student/Spouse Information
Estimated 2017 Taxable Income
Student’s earned income $ _______________.00
Spouse’s earned income (if applicable) $ _______________.00
Other taxable income* $ _______________.00
Total taxable student income $ _______________.00
* including, but not limited to, unemployment compensation, alimony received, distributions from Ira/pension/annuity, business income, gains, etc.)
Estimated 2017 Non-taxable Income
Child support received $ _______________.00
Other non-taxable income** $ _______________.00
Total non-taxable student income $ _______________.00
** including, but not limited to, untaxed portions of IRA/pension/annuity disbursements, IRA deductions and payments, tax exempt interest income, etc.)
I (We) certify that I (we) have read all instructions and attached all required documentation to allow for a thorough review of
this appeal. I (we) also realize that completing this form does not guarantee an increase to the current financial aid award.
Student’s signature
Parent’s signature
Date
Date
Office of Financial Aid
300 College Park
Dayton, Ohio 45469 -1605
FAX: 937-229-4338
www.finaid.udayton.edu
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Appeal Form 17-18

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Completed 24 February 2020

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