Fillable Dependent Permanent Total Disability Form 2019 20 (University of Maryland - Global College)

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Dependent Permanent Total Disability Form 2019 20 (University of Maryland - Global College)

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Award Year 2019-2020 FPJDSB
UMGC Financial Aid Office | 3501 University Boulevard East, Adelphi MD 20783 | help.umgc.edu
Page 1 of 2
Dependent Student Special Conditions Appeal Form: Permanent and Total Disability
Student’s Name: __________________________________
Student’s ID #: ___________________________________
If your family has experienced significant changes in income that occurred on or after 01/01/2018 and which
merit recalculating your financial aid eligibility based on your projected annual 2019 income rather than the
federally-required 2017 income, please complete this form. You must be able to document that the reduction of
income has occurred for a period of at least ten weeks prior to submitting the appeal.
Before your appeal can be considered, your 2019-2020 Free Application for Federal Student Aid (FAFSA) must
be completed and all required documents must be submitted. UMGC is held accountable for all decisions made
and must be able to fully document why a decision was made to adjust a student’s FAFSA. If an appeal is
incomplete, it will not be reviewed. Submission of an appeal does not guarantee approval of an appeal.
Additionally, approval of an appeal does not guarantee receipt of additional aid. You are responsible for all
outstanding charges with UMGC.
Required Documents: If a document listed below is not applicable to your situation, please submit a signed
statement indicating why you do not have the document.
1. Completed appeal form – both pages
2. A typed statement that explains your circumstances in detail – must be signed by hand and dated
3. 2017 Tax Return Transcript for student
2017 Tax Return Transcript(s) for parent(s)
4. 2017 Wage and Income Transcript for student
2017 Wage and Income Transcript(s) for parent(s)
5. The final / most recent 2019 pay-stubs for all members of your household (as defined in Part 3)
6. Termination notice(s) from employer(s) or letter(s) of resignation
7. Disability benefits statement(s) from the Social Security Administration
INSTRUCTIONS: Please provide all information requested in the following sections. If any are left incomplete,
your appeal will not be reviewed.
Part 1: List all asset information as of the date you initially filed your 2019-2020 FAFSA:
Total cash, savings, and checking account balance(s): $_________________________Balance
Financial Aid Office Use Only
Date__________________________________
Approved ________ Denied ____________
Signatures ____________________________
_________________ __________________
_________________ __________________
_________________ __________________
Appeal Deadline
Complete appeals for the 2019-2020 academic
year must be received by May 1, 2020.
Page 2 of 2
Part 2: List all projected annual income and benefits from January 1, 2019 to December 31, 2019.
SOURCE OF INCOME (projected until end of the year)
PARENT 1
PARENT 2
STUDENT
Wages, salaries, tips (including severance pay)
$
$
Pensions and Annuities
$
$
Interest and /or Dividend Income
$
$
Business/farm Income
$
$
Unemployment Compensation
$
$
Alimony
$
$
Social Security/SSI Benefits
$
$
Workers Compensation
$
$
Disability Benefits
$
$
Retirement Benefits
$
$
Child Support
$
$
Welfare Benefits/ TANF
$
$
Other Untaxed Income
$
$
TOTAL INCOME
$
$
$
Part 3: Please complete the chart below by listing all members of your parent(s)’ household. Include the name
of the college for any household member who will be enrolled at least half-time in a degree or certificate
program at a postsecondary educational institution any time between July 1, 2019 and June 30, 2020. If
additional space is needed, use an extra page. The definition of “household” is:
Yourself, even if you don’t live with your parent(s)
Your parent(s) (including a step-parent) regardless of current marital status or gender
Your parent(s)’ other children, if your parent(s) will provide more than half of their financial support
from July 1, 2019 to June 30, 2020, or if the other children would be required to provide parental
information if they were completing a FAFSA for 2019–2020.
Other people who now live with your parent(s), if your parent(s) provide more than half of their support
and will continue to provide more than half of their support through June 30, 2020.
STATEMENT OF CERTIFICATION
All of the information on this form is true and complete to the best of my knowledge. If requested, I agree to provide further
documentation to substantiate the information provided. I understand that all special circumstances are reviewed on a case-by-case
basis and this written request does not guarantee approval and/or may not ultimately result in an actual change to the financial aid
already offered. All persons providing information must sign below.
Student’s Signature ____________________________________________________ Date _______________________
(must be signed by hand, not typed)
Parent’s Signature _____________________________________________________ iDate _______________________
(must be signed by hand, not typed)
Full Name
Age
Relationship
College (student will be enrolled at least half-time)
Self
University of Maryland Global Campus
Parent 1
Parent 2
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Dependent Permanent Total Disability Form 2019 20 (University of Maryland - Global College)

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Completed 27 July 2020

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