Cost of Attendance Adjustment Request
Financial Aid Office 155 Indian Ave. Lawrence, KS 66046
785-749-8468
Fax 785-832-6617
@haskell.edu
Federal financial aid regulations allow financial aid administrators to adjust your cost of attendance if you have Special
Circumstances/expenses which your current estimated cost of attendance does not cover. To determine if adjustments
can be made to your set cost of attendance, please complete the appropriate sections below and return this form with
the applicable documentation. Requests are reviewed on a case-by-case basis and submission of this form does
not guarantee an adjustment to your financial aid eligibility.
Last Name First Name MI
Haskell ID# Phone number (include area code)
Fall Semester Spring Semester Summer Semester
Course Fees/Books/Supplies: I paid more than the estimated amount for my course fees, books, and/or supplies.
• Provide a copy of your student account. If you have other receipts for books and/or supplies, please include
those with your request. $
Room & Board: I paid more than the estimated amount for my room and board.
• Provide a copy of your student account if you have dorm charges.
• Provide a copy of your lease agreement indicating your portion of the rent.
• Provide copies of your receipts detailing your monthly grocery bill.
• Provide copies of the most recent utility statements (i.e. water, trash, electricity, internet, etc.) indicating your
portion.
Note: Adjustments made for this category must reflect a reasonable expense; not all adjustments will be accepted due to
the lifestyle choice of the student.
Computer purchase: I purchased or leased a computer. A one-time only adjustment is allowed during your
undergraduate and/or graduate education).
• Provide documentation of the cost of the computer you purchased/leased (e.g., receipt of purchase, lease
agreement or cost estimate) $
Transportation:
I have transportation expenses needed to complete my course(s) of study. (Not considered: purchase of a vehicle, auto
loan payments, insurance, license, registration, and general maintenance)
• Provide copies of receipts or cost estimate of necessary transportation expenses $_
Dependent Care:
I have dependent care expenses.
• Provide copies of receipts/contract indicating monthly payment amount. $
Miscellaneous:
I have other education related expenses that do not fit in any other category.
• Provide appropriate documentation and, if needed, a letter describing the education related expenses for
consideration. $
By signing this form, I certify that the information provided within this request is accurate. I agree to provide the
Financial Aid Office additional information if necessary. I acknowledge that I may be liable for repayment of any financial
assistance received if the information that I am providing is inaccurate.
Student Signature Date
FOR OFFICE USE ONLY
Adjustment made: $
Semester
Date
click to sign
signature
click to edit
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