Indian River State College
Office of Financial Aid
3209 Virginia Avenue Fort Pierce FL 34981
(772) 462-7450
2019-2020 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 (was
paid by you) 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. 8/2019
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:
(Required for Dependent Students Only)
Reviewed Date: Reviewed by: Approve Deny Cancel Request
Rev. 8/2019
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