2022-2023 Request for Special Circumstance
2023 CFSPEC
CSN Financial Aid Office ǀ West Charleston Campus ǀ North Las Vegas Campus ǀ Henderson Campus
Phone: 702-651-4303 · Fax: 702-651-7495 · Email: finaid@csn.edu · https://www.csn.edu/financial-aid
Student Name: NSHE ID:
This form is for students and/or their families experiencing a significant change in their financial circumstances to appeal for
a recalculation of their financial aid eligibility based on the current conditions.
Students selected for verification must
complete the verification process before a Special Circumstance is processed. Please be advised that all Professional
Judgment appeal decisions are final.
Section 1: INSTRUCTIONS
1.
Complete and submit this Special Circumstances Request form to the Office of Financial Aid.
2.
Submit a signed statement explaining your situation related to the circumstances below. Please include any relevant dates
in your statement.
3. Submit all required documentation based on the circumstance that best fits your situation
Section 2: CIRCUMSTANCES - Select the circumstance that applies to your situation and attach the required paperwork.
DEPENDENT STUDENTS: for the items listed below, submit the documentation for you and your parent(s)
INDEPENDENT STUDENTS: for the items listed below, submit the documentation for you and your spouse (if married)
☐ Loss of substantial taxable income since the 2020 tax year because of loss or change in employment due to
extenuating circumstances for a period of 10 weeks or longer during the 2022 year.
1. Signed copy of you and your spouse’s (if married) OR you and your parent’s 2021 tax return
2. Letter or documentation from all previous employer(s) in 2022 indicating dates of employment
3. Most recent pay stub(s) indicating year-to-date earnings from all jobs in 2022
4. If receiving unemployment benefits, the most recent unemployment compensation statement. If you’re not
receiving unemployment, please address it in your personal statement and provide a copy of the denial notice
☐ Loss of substantial untaxable income (e.g., child support, disability benefits, and worker’s compensation)
1.
Copy of Notification of benefits reduction/termination, including the effective date
2.
Documentation of 2022 income (taxable and non-taxable)
☐ Excessive non-reimbursed medical and/or dental expenses not covered by insurance
1.
Documentation of non-reimbursed medical and/or dental expenses (i.e., receipts for medical services)
OR
2.
Copy of Schedule A Form from 2020 Federal Tax Return
☐ Separation, Divorce, or Death of a spouse which occurred AFTER applying for financial aid
1.
Copy of court order, final divorce decree, or legal separation agreement
2. If not legally separated, a signed statement of separation and proof of separate households (i.e., copy of lease
agreements, utility bills showing address)
3. Signed copy of 2020 taxes and all W-2/1099’s from both persons
4. Copy of death certificate, if applicable
5. Complete Section 3, Household Size section (page 2)
☐ Distribution of 401K or similar due to financial hardship included in the 2020 adjusted gross income.
1. 2020 IRS Tax Return Transcript or signed copy of 2020 Tax Return and
2. 2020 W-2 forms for all jobs held and 2020 1099R form
3. A signed statement detailing the situation and how funds were utilized. Indicate if any funds are remaining.
4. Copy of mortgage or rent documents showing the monthly amount, if funds used to assist in payments
☐ One-time income received in 2020 that was included in the 2020 adjusted gross income.
1. 2020 IRS Tax Return Transcript or signed copy of 2020 Tax Return and
2. 2020 W-2 forms for all jobs held in 2020 and 2020 1099R form
3.
A signed statement explaining the type and amount of one-time income received in 2020 and not in 2021 and 2022
