1100 Co
ll
ege Drive I Mena, Arkansas
71
953
Phone: 479.39
4.7
622 I Fax: 479.39
4.5
329 I www.uaric
hm
ountain.e
du
Required Documentation for Extenuating Circumstances
1. Loss of employment or change in employment status (Attach the following to this form)
Signed statement from the student explaining reason for unemployment
Last pay stub showing year to date earnings for 2021 or a statement from your previous
employer documenting year to date income
Documentation of all untaxed income received in 2021
2. Divorce or separation of student or parent (attach the following to this form)
Divorce decree (copy)
Separation – copy of legal separation document, a signed statement from your attorney
showing the date of separation, or a statement from an unrelated third party
3. Death of a spouse or parent (attach the following to this form)
A death certificate or an obituary notice
4. Loss of untaxed income (attach the following to this form)
A copy of a letter from the agency that provided benefits detailing termination of benefits
and copies of summaries of benefits
5. Unusual medical or dental bills or handicapped-related expenses (attach the following to this
form)
A copy of schedule A of the Federal 1040 form
Canceled checks or receipts showing amount paid with statement from insurance company
showing expenses were not reimbursed
6. One time payments that caused income to be overstated (attach the following to this form)
Detailed written explanation and documentation
7. Other:
Pertinent documents supporting your request for reconsideration
Submit request form and all other required documents to the following address:
UA Rich Mountain
Financial Aid Office
1100 College Drive
Mena, Arkansas 71953
