**Please complete this form using only black or blue pen**
Name ____________________________________________________ Student ID (700 #) ________________________________
Street Address _____________________________________________________________________________________________
Email __________________________________________________________ Phone______________________________
Reason for Appeal (check one): Low GPA ______ Low Credit Hours _____ Withdrew From All Courses _____
All F’s _____ Maximum Credit Hours _____
If the reason for your ineligibility is a low GPA, low credit hours, getting all F’s or withdrawing from all courses, then
you must submit this form AND provide both items below to the Financial Aid Office.
1) Attach a typewritten and signed statement fully explaining the circumstances during the semester of failed academic
progress. Be specific and thorough. Include all pertinent information you feel is beneficial to your appeal. Also provide an
explanation of the steps you have taken, or will take, to improve your academic progress.
2) Provide documentation that supports your appeal such as:
a. Medical documentation of the condition that resulted in your loss of eligibility and subsequent medical documentation
that shows that your medical condition has been resolved and is no longer an issue.
b. Documentation of a death in the family.
c. Documentation of any other extenuating circumstances that are not medical or death related.
d. Documentation of a signed academic contract with a student mentor in Albers Hall.
If the reason for your ineligibility is because you exceeded the maximum credit hours for your current degree program,
then you must submit this form AND complete the information below along with providing the documentation
requested to the Financial Aid Office.
1) Have you changed your major during attendance at Colorado Mesa University? Yes _____ No _____
2) Expected date of graduation ________________________
3) How many academic years have you received financial aid? __________________________
4) Provide both items listed below:
a. Attach a typewritten statement as to why you have accumulated an excessive number of credit hours and have not
b. A signed statement from your faculty advisor that provides a brief summary of the remaining course work plan by
semester including the date that you will graduate. An email from your advisor directly to the Financial Aid office
with this information is also acceptable. DegreeWorks reports or planning sheets are not sufficient.
I certify that all the information on this form is true and accurate. Any aid awarded to you based on false or misleading information
may result in repayment of any financial aid received. Allow 2-3 weeks for your review. You will be notified of the decision by mail.
Student’s Signature ___________________________________________________________ Date________________________