Fillable EAST TENNESSEE STAT E 2020-2021 Submission Deadline 2/28/21 (East Tennessee State University)

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EAST TENNESSEE STAT E 2020-2021 Submission Deadline 2/28/21 (East Tennessee State University)

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,______
___
I
•
EAST
TENNESSEE
STAT
E
UNIVERSITY
OFF
I
CE
OF
Financial Aid
2020-2021 Submission Deadline – 2/28/21
Special Circumstances Appeal Form
Name ETSU ID Number E _
Address City/State/Zip:
_ _
The Office of Financial Aid recognizes that many families have changes in income or family situations that cannot be
reflected in the 2018 tax return. Therefore, it is possible for students to appeal their financial aid eligibility if they
have unique financial circumstances. If selected for verification by the Department of Education, you must complete
verification before submitting this request. Notification of the Committee’s decision will be sent to your ETSU email
address. All Committee decisions are final and not appealable to the U.S. Department of Education.
A Special Circumstances Appeal may be filed if you or your family have extenuating circumstances, which you believe
warrant a reevaluation of your financial aid. Circumstances may include:
•
Loss or change of employment
• Loss or change in untaxed income (child support, Social Security, or other benefits)
•
Divorce or separation of parents or spouse
•
Death of parent(s) or spouse
•
Unusual medical expenses (not covered by insurance)
•
One-time taxable income used for life changing events (e.g. IRA, pension distribution, back-
year Social Security
payments)
Circumstances that are NOT considered extenuating include, but are not limited to:
•
Standard living expenses (e.g. utilities, credit card payments, children’s allowances, etc.) Mortgage
•
Car payments
•
Credit card or other personal debts
•
Vacation expenses
•
If the student’s Estimated Family Contribution (EFC) is already zero (0), the appeal will not be reviewed due to the fact
that the student is already eligible for the maximum federal financial aid available. Exception: a budget increase request.
All appeals require Tax Return Transcripts for student and parent (if student is dependent) along with W2’s and/or
1099’s used to complete the tax return. You may obtain a 2018 Tax Return Transcript by going online to
https://www.irs.gov/individuals/get-transcript or you may call the IRS at 1-800-908-9946 and follow the prompts to
request. Copies of 1040, 1040A, or 1040EZ forms cannot be accepted. Special Circumstance Appeals received after
11/1/20 will not be considered until a 2020 Tax Return Transcript and 2020 W2’s and/or 1099’s have been submitted.
Student Name:
Student ID#:
THIS APPEAL WILL NOT BE ACCEPTED WITHOUT THE REQUIRED SUPPORTING DOCUMENTATION ATTACHED. Failure to
provide adequate documentation will result in your appeal being denied.
Allow 3 to 4 weeks for processing from the time a complete appeal package has been submitted. During peak times
processing may take longer. Submitted documentation will not be returned. Please do not submit originals.
Submission
of this form with your signature verifies that you have read the procedures above and that all your statements are true
and accurate. DO NOT EMAIL documents with Personally Identifiable Information (PII) (i.e. SSN, Full Name, Phone #,
Address…).
Check Box
Reason
Required Documentation
Significant loss of income/loss of
employment for at least 3 months
(Student, Parent(s), Spouse)
*Requests involving self-
employment, commission, tips or
other variable income will generally
not be reviewed until the end of the
calendar year due to the complexity
of estimating yearly income.
Requests may also be delayed until
the end of the calendar year if
income is undeterminable, if the
•
Special Circumstances Appeal form
• Student/Parent (if dependent) Asset Form
• Verification Worksheet
• Signed/dated detailed letter explaining your circumstances
• 2018 Tax Return Transcript from IRS website for student and
parents (if dependent).
Copies of 1040, 1040A or 1040EZ are not acceptable.
• W-2’s for student and parents (if dependent)
• Letter from former employer(s) stating the last date of
employment
• Copy of unemployment compensation letter or signed statement
that you did not or will not receive unemployment benefits
affected member is seeking
employment and has obtained
employment, or if you or your
parents itemize deductions with a
Schedule A on your tax returns.
□ For Job Loss Appeals there is a
waiting period of 12 weeks
from date of termination
•
Copy of last 3 paystubs from former employer(s) andcurrent
employer(s), if applicable.
• If this form is submitted after 11/1/2020, 2020 Tax Return
Transcripts and W-2’s should be submitted for student (spouse)
and parents (if dependent)
• Copy of DD214 if appeal is due to discharge from active
military duty
May be applicable:
Proof of severance package benefits
Proof of pension income
Proof of other income (1099, Roth IRA Statement)
Student Name:
Student ID#:
Death of a parent or spouse that
occurred after filing of FAFSA
•
Special Circumstances Appeal form
• Student/Parent (if dependent) Asset Form
• Verification Worksheet
• Signed/dated detailed statement explaining circumstances
• 2018 Tax Return Transcript from IRS website for student and parents
(if dependent) Copies of 1040, 1040A or 1040EZ are not acceptable.
• W-2’s for student and parents (if dependent)
• Copy of death certificate
Loss of Untaxed Income (social
security, disability, child support,
alimony, unemployment, etc.)
•
Special Circumstances Appeal form
• Student/Parent (if dependent) Asset Form
• Signed/dated detailed letter explaining circumstances
• 2018 Tax Return Transcript from IRS website for student and parents
(if dependent)
Copies of 1040, 1040A, or 1040EZ are not acceptable
• W-2’s for student and parents (if dependent)
• If benefit terminated, provide documentation of monthly benefit
amount and date of benefit termination.
• If benefits reduced, provide documentation of original
amount, date of reduction and reduced amount.
Separation/Divorce of Student or
Parent (occurred after filing of
FAFSA)
□
Special Circumstances Appeal form
□
Student/Parent (if dependent) Asset Form
□
Verification Worksheet
□
Signed/dated detailed statement explaining circumstances, including
income student/parent will receive in 2020 as result of divorce.
□
2018 Tax Return Transcript from IRS website for student and parents
(if dependent) Copies of 1040, 1040A or 1040EZ
are not acceptable.
W-2’s for student and parents (if dependent) Copy of
legal separation documentation
Proof of separate households (utilities bills, etc.)
Copy of final divorce degree with attached settlement/ mediation
agreement
Unusual Out-of-Pocket Medical
Expenses (expenses NOT paid by
insurance provider)
□
Special Circumstances Appeal form
□
Student/Parent (if dependent) Asset Form
□
Verification Worksheet
□
Signed/dated detailed letter explaining circumstances
□
2018 Tax Return Transcript from IRS website for student and
parents (if dependent) Copies of 1040, 1040A, or
1040EZ are not acceptable
□
W-2’s for student and parents (if dependent)
□
Proof of out-of-pocket payment (cancelled checks, credit card
statements, receipts, etc.)
Student Name:
Student ID#:
Copy of Schedule A from 2018 tax return to reflect itemization
Statement from pharmacy indicating amount paid for
prescriptions and name of patient
Statement from physician indicating out-of-pocket payments and name of
patient
One time taxable income used for
life changing event (IRA, Pension
distribution, back-year Social
Security payments, back-year child
support payments, etc.)
□
Special Circumstances Appeal form
□
Student/Parent (if dependent) Asset Form
□
Verification Worksheet
□
Signed/dated detailed letter explaining circumstances
□
2018 Tax Return Transcript from IRS website for student and parents
(if dependent) Copies of 1040, 1040A, or
1040EZ are not acceptable
□
W-2’s for student and parents (if dependent)
□
Documentation to identify source of the one-time taxable income
□
Proof of payment and an itemized statement indicating how the funds
were spent (cancelled checks, receipts, bank statements, etc.)
Marriage of Student (after filing of
FAFSA)
□
Special Circumstances Appeal form
□
Student/Parent (if dependent) Asset Form
□
Verification Worksheet
□
Signed/dated detailed letter explaining circumstances and current
household size
□
2018 Tax Return Transcript from IRS website for student and spouse
Copies of 1040, 1040A, or 1040EZ are not acceptable
□
W-2’s for student and spouse
□
Copy of marriage certificate
Student Name:
Student ID#:
My signature below certifies the information I have provided on this form and attached documentation is true and
complete to the best of my knowledge. I agree to
provide proof of the information if and when requested. I understand
that the penalty for providing false or misleading information is a $20,000 fine, a prison sentence, or both.
Student Signature
Date
Parent/Spouse Signature
Date
To submit the completed form: In person: Office of Financial Aid, Burgin-Dossett – Room 105;
Mail: Office of Financial Aid, P.O. 70722, Johnson City, TN 37614;
Fax: (423) 439-5855;
DO NOT EMAIL documents with Personally Identifiable Information (PII) (i.e. SSN, Full Name, Phone #, Address…).
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EAST TENNESSEE STAT E 2020-2021 Submission Deadline 22821 (East Tennessee State University)

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Completed 8 December 2020

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