2018-2019
Income Adjustment
Student ID
Last Name First Name
You are submitting this appeal to adjust your Expected Family Contribution (EFC) based on a change in and/or a reduction in your or
your parent’s/spouse's 2017 earnings and/or benefits. Please complete the sections below and provide the requested
documentation.
Section 1: Reason for Loss of Income and Benefits in 2017
_____My Parent’s and/or
_____My 2017 income and/or benefits will be LESS than 2016 due to (check box below):
_____Loss of Employment
_____Loss of Benefits (i.e. SSI, TANF, Child Support, Alimony)
Job
Change
_____Reduction in
Work Hours
_____Retirement
Please write a brief statement explaining the change in income from 2016 to 2017 (attach additional page(s) if needed):
Section 2: 2016 Supporting Documentation to be submitted with this form:
_____Parent 2017 IRS Tax Transcript or Return
_____Student 2017 IRS Tax Transcript or Return
_____Verification of Non-Tax Filing Letter from the IRS
_____If you or your Parents 2018 Income is less than 2016 AND 2017 please see a Financial Aid Advisor
If Submitting after January 1, 2019, please submit a copy of your/your parents 2018 IRS Tax Transcript.
Parents whose primary source of income is gained through self-employment are not allowed to project their income if the business is still operational. If
your business is non-operational by December 31st, 2017, you may submit an appeal. However, appeals based on loss of self-employment earnings
must be accompanied by your 2018 federal tax transcript in order for the re-evaluation to be completed.
Certification: I/We hereby certify that all the information reported on this form and any attachments hereto are true, complete, and accurate. Further,
I/we understand
that false
statements
and /or
misrepresentation
will result in denial, reduction,
withdrawal,
and/or repayment of aid disbursed, as well as student disciplinary action. I/We understand that
the calculation of the EFC may not result in
eligibility for the Federal Pell grant or need based financial aid.
Student Signature Date ______________
Parent Signature Date
Adjustment Approved Adjustment Denied Adjustment Will Not Change Eligibility for Aid
Comments:_______________________________________________________________________________________________________________
Approved By Date
1570 East Colorado Blvd.L-114, Pasadena, California 91106
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2003 19INAD
