Office of Financial Aid • 1420 N. Charles St. • Baltimore, MD 21201 • p: 410.837.4763 • f: 410.837.5493 • financialaid@ubalt.edu
Dependency Status Request Appeal Form
The Dependency Status Appeal Form can be used if you have an extenuating circumstance that may hinder you from
successfully completing your Free Application for Federal Student Aid (FAFSA). The Office of Financial Aid must have
documented proof of the extenuating circumstance that prevents the student from obtaining parental data for the FAFSA
form. The following documentation MUST be provided: (Please note, federal guidelines state that the following
situations alone are not considered “extenuating circumstances”: 1) Your parents are unwilling and/or unable to
financially support you. 2) You live on your own and pay your own bills. 3) Your parents refused to provide information
required for completion of the FAFSA or verification).
A. STUDENT INFORMATION
Last Name First Name M.I. Student ID Number (begins with 1 or 3)
Email Address Telephone Number Date of Birth
B. APPEAL CONTENTS
□ Appealing for 2018-2019 Aid Year or
□ Appealing for 2019-2020 Aid Year.
□ A typed and signed explanation of your exceptional circumstance. Your explanation must be clear, concise,
and must include a complete history of the following:
• Your relationship with your biological and/or legally adoptive parents – include their first and last
names and when you last spoke with each parent.
• How long you have been separated from your parents and specific dates that led up to your
separation.
• If you have any siblings, please provide their first and last name. Include where they live and with
whom, and describe your relationship with them since the separation from your parents.
• How you have been supporting yourself. You should include if you have auto/health insurance and
who pays for the insurance, including a copy of the card(s).
□ A copy of your birth certificate.
□ A signed letter from a professional (on their letterhead) documenting their knowledge of your exceptional
circumstance. The letter must include the professional’s contact information. (A professional includes college
or high school counselors, mental health professionals, social workers, mentors, doctors, clergy, etc.).
C. SIGN THIS WORKSHEET
By signing this worksheet, I (we) certify that all the information reported on this worksheet to qualify for federal student
aid is complete and correct. If you are dependent for financial aid purposes, at least one parent must sign. Warning: If you
purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
______________________________ __________
Student’s signature Date
click to sign
signature
click to edit
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