FINANCIAL AID OFFICE
1000 East Victoria Street, WHB250
Carson, California 90747
PHONE: (310) 243-3691
Student’s Name: ______
2021-2022 Income Adjustment Appeal Form
Your 2021-2022 financial aid application reflects income information from the 2019 calendar year. If you or your family’s financial
situation has changed, you may request to have your financial aid eligibility re-evaluated using 2020 or 2021 income information.
Please complete this form and submit the required documentation to the Financial Aid Dropbox located at: csudh.edu/financial-
aid/forms/. You will be notified via your Toromail account once your appeal has been reviewed. The deadline to submit this form and all
required documents is Thursday, April 22, 2022.
Tell us the Person(s) impacted by change (check all that apply): Student Spouse Parent(s)
Submit the following items:
A typed statement that provides a detailed explanation regarding the change in income. Include the month and year the change occurred.
This statement should be signed by the person impacted by the change.
Supporting documentation specific to your situation: Examples below
Loss of job (attach the following items and the required documentation indicated below)
o Letter from employer showing the last date worked; or
o Copy of most recent pay check stub(s) showing year-to-date earnings; or
o Copy of unemployment benefit letter (EDD).
Reduction of work hours (attach the following items and the required documentation indicated below)
o Copy of most recent pay check stub showing year-to-date earnings
o Date reduction occurred: Hourly Pay Rate: Current Hours Per Week:
Other circumstance(s): Please explain and attach appropriate documentation
o For example: Divorce/Separation after filing your FAFSA or CA Dream Application.
2021-2022 Dependent (or) Independent Verification Form and a signed copy of the 2019 U.S. Individual Income Tax Return (Form 1040)
(if not previously submitted).
Check here: If the IRS Data Retrieval Tool (DRT) was used on 2021-2022 FAFSA.
If a tax return was not filed for 2019, please submit an IRS Verification of Non-Filing letter and explain in a signed, typed
statement how you, your spouse, and/or your parents were able to meet basic living expenses (food, housing, etc.).
Include specific dollar amounts and source of all support (monetary support from others, Veteran’s Benefits, financial aid
If the change occurred in 2020, submit a Signed copy of the 2020 U.S. Individual Income Tax Return (Form 1040).
If this form is submitted after January 1, 2022 and 2021 was the year the income was impacted submit a signed copy of
2021 U.S. Individual Income Tax Return (Form 1040).
The signature(s) below certify that this information is true and gives the Financial Aid Office at CSUDH permission to make changes to
my financial aid offer based on this request.
Student Signature (Required) Date Parent Signature (required for dependent student) Date
click to sign
click to edit
click to sign
click to edit