Rev. 3/2020
Indian River State College
Office of Financial Aid
3209 Virginia Avenue Fort Pierce FL 34981
(772) 462-7450
2020-2021 Special Circumstances Form
Student Name: Last: First: Middle:
IRSC Student ID: Date of Birth:
Home Phone: Work Phone:
Street Address:
City: State: Zip:
Unusual Medical or Extraordinary Expenses
(You must provide supporting documentation)
This form should only be used if you (and/or your spouse if married) or parent (if a dependent
student) have experienced unusually high medical, household or other extraordinary expenses that
were beyond your control. Please explain the circumstances that led to the unusual expenses. You
must provide supporting documentation, including most current income information,
insurance policy information and other documentation that will support your claim. (Please
use a separate sheet of paper if you need additional space.)
Rev. 3/2020
CERTIFICATION
I understand that submission of a Special Circumstances Form to the Financial Aid Office does not
guarantee that I will become eligible to receive need-based aid including the Pell Grant. By signing
this application, I certify that the information on this form and contained within the supporting
documentation is true, correct and complete to the best of my/our knowledge. Both the student
and the spouse or at least one parent (if you are a dependent student) must sign this form.
Student’s Signature: Date:
Spouse’s Signature: Date:
Parent’s Signature: Date:
(Required for Dependent Students Only)
FOR OFFICE USE ONLY
Reviewed Date: Reviewed by: Approve Deny Cancel Request
IRSC is an EA/EO educational institution
SERVING . . INDIAN RIVER, MARTIN, OKEECHOBEE AND ST. LUCIE COUNTIES
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