Fillable Appeal-additional-federal-assistance19-20 Financial Aid 2019-2020 Appeal For Additional Federal Assistance Form (Hudson Valley Community College)

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Appeal-additional-federal-assistance19-20 Financial Aid 2019-2020 Appeal For Additional Federal Assistance Form (Hudson Valley Community College)

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HVCC Financial Aid Office Phone 518-629-7150 Guenther Room 110
80 Vandenburgh Ave Fax 518-629-7479 Monday-Friday
Troy, NY 12180 financialaid@hvcc.edu 8AM-5PM
2019-2020 Appeal for Additional Federal Assistance
The Financial Aid Office at Hudson Valley Community College recognizes that students and their families may experience unforeseen
circumstances and/or expenses during an academic year. This form is designed to address your possible eligibility for additional
funding as a result of such circumstances. Please note: Your circumstance must have occurred due to issues beyond your control.
Circumstances such as, but not limited to, voluntarily leaving employment to attend college or retirement will not be considered for
an appeal. Complete requests must be submitted no later than MARCH 1, 2020.
A-1. Changes in income have occurred for: (check only one)
Parent of dependent student
Student/spouse
Please check all conditions that apply and submit all required documentation as listed below.
DECREASE IN INCOME DUE TO: DATE OCCURRED
Loss of Wages, tips, salary, etc. __________________
Receipt or loss of Unemployment benefits __________________
Disability __________________
Reduced or terminated untaxed income __________________
(child support, untaxed pension, etc.)
Death of Dependent Student’s Parent __________________
Death of Independent Student’s Spouse __________________
Separation or divorce __________________
Other (_____________________________) __________________
Required Documents: ALL required documentation listed below must be submitted before we can review your
situation.
1. Completed 2019-2020 Verification Worksheet (if not previously submitted).
2. Student’s 2017 Federal tax return transcript*, W2 forms and other income documents.
3. Spouse’s separate 2017 Federal tax return transcript*(if student is married and filed taxes separately), W2
forms and other income documents.
4. Parent(s) 2017 Federal tax return transcript*, W2 forms and other income documents (if dependent).
5. Proof of situation, such as: letter from employer regarding change in employment, physician’s statement
regarding disability, lawyer’s statement regarding separation, court statements regarding divorce or
termination of child support, or death certificate.
6. Signed copy of 2018 federal tax returns, W2 forms and all other income statements (unemployment,
pension, etc.).
*If an IRS Data Match was used to provide 2017 tax information on the FAFSA, we must request a signed copy of the 2017
federal tax return to review the appeal.
NOTE: If you are submitting your appeal form after January 1, 2020
, we will require a signed copy of your 2019 federal tax
return, W2 forms and other financial documentation.
Student Name
H00
SECTION A: Involuntary loss in Income (Complete Sections A-1, A-2, C and D)
A-2. Please complete this page using 2018 income only for the person(s) having the special situation as indicated in
Section A-1. Enter “0” if any item does not apply. We cannot assume a blank line to mean “0” or “none”.
You must submit documentation of ALL income.
Student Spouse (if married)*
Parent(s) (if dependent)*
Gross wages, salaries, tips etc. $______________ $_______________ $_____________
Unemployment Benefits $______________ $_______________ $_____________
Alimony Received $______________ $_______________ $_____________
Social Security Benefits $______________ $_______________ $_____________
AFDC/TANF $______________ $_______________ $_____________
Child Support Received $______________ $_______________ $_____________
Any other untaxed income or benefits such as worker’s compensation, disability, veteran’s non-education benefits,
housing, food or other allowances provided to members of the military or clergy, etc.
Benefit Type: _______________ $______________ $_______________ $_____________
Benefit Type: _______________ $______________ $_______________ $_____________
* If you or your parents are recently separated, divorced or widowed, do not include former spouse’s income or
benefits.
B-1. Medical expenses you paid out of pocket. This amount must be higher than the standard estimates assigned by
the federal financial aid formula. Please ask a Financial Aid Office representative for the standard estimate before you
attempt to complete this section.
Total medical insurance premiums paid in 2017 or 2018 $_____________________
Total medical expenses not covered by insurance and paid in 2017 or 2018 $_____________________
B-2. Required Documents: (ALL required documents must be provided before we can review your situation.)
1. Completed 2019-2020 Verification Worksheet (if not previously submitted)
2. Signed copy of your 2017 Federal tax return transcript*, W2 forms and other income documents.
3. Signed copy of your spouse’s separate 2017 Federal tax return transcript*(if filed separately), W2 forms
and other income documents (if married).
4. Signed copy of your parent(s) 2017 Federal tax return transcript*, W2 forms and other income documents
(if dependent).
5. Proof of all expenses paid in 2017 or 2018 (i.e. receipts or cancelled checks, etc.)
If submitting proof of expenses paid in 2018, please also submit a signed copy of your 2018 federal
tax return, W2 forms and other income documents.
*If an IRS Data Match was used to provide 2017 tax information on the FAFSA, we must request a signed copy of the 2017
federal tax return to review the appeal.
NOTE: If you are submitting your appeal form after January 1, 2020
, we will require a signed copy of your 2019 federal tax
return, W2 forms and other financial documentation.
SECTION B: Extraordinary Medical Expenses (Complete Sections B-1, B-2, C and D)
Please write a summary of your special circumstances. Please include all relevant dates. You may attach a separate
sheet if necessary.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I certify that the information provided on this form is true and complete to the best of my knowledge. I have attached
all required documentation and I agree to provide additional documentation if requested. I further agree to notify the
HVCC Financial Aid Office of any error or omission in the above information. I understand that failure to comply with
this agreement could result in forfeiture of financial aid for the student. I also understand that I can submit an Appeal
for Additional Federal Assistance only once during my attendance at Hudson Valley Community College.
____________________________________________________ ______________________________
Student’s Signature Date
____________________________________________________ ______________________________
Spouse’s Signature (if married) Date
____________________________________________________ ______________________________
Parent’s Signature (if dependent) Date
Hudson Valley Community College does not discriminate on the basis of gender, race or ethnicity, national origin,
religion, disabling condition, marital status or sexual orientation.
Approved Corrected TR ______, Expect TR ______, EFC=______
PJ Flag in CPS______ (check RNANA20 and RNIMS20)
Letter Sent, Copy in File
PJDOCS _____
SECTION C: Explanation of Change
SECTION D: Signatures
PLEASE NOTE: FAILURE TO SUBMIT ALL REQUIRED DOCUMENTATION WILL RESULT IN THE UNPROCESSED RETURN
OF THIS REQUEST. COMPLETE REQUESTS MUST BE SUBMITTED NO LATER THAN MARCH 1, 2020.
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Completed 27 July 2020

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