LOSS OF INCOME APPEAL
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**Please complete this form using only black or blue pen**
Name __________________________________________________________ Student ID (700 #) _________________________
Street Address _______________________________________________________________________________________________________
City_________________________________________________________State________________________Zip_________________________
Email _________________________________________________________ Phone___________________________________________
STEP 1:
Place a check mark (√) next to the line(s) A-F below that best describes your situation AND provide the
documentation listed with that item.
A _____ Payment of private el
ementary and/or secondary tuition.
Provide documentation of amount paid.
B _____ Unusually high medical or dental expenses.
Provide an itemized list of out-of-pocket expenses AND provide official documentation of those out-of-pocket expenses.
Do not include any amount paid by insurance.
C _____ Loss of employment. (May include but not be limited to job termination, retirement, or due to a natural disaster.)
Provide documentation such as termination notice and/or retirement letter.
D _____ Loss of non-taxable income. (Such as child support, social security, retirement benefit, TANF, or welfare.)
Provide notification of termination of benefits statement from agency.
E _____ Loss of other taxable income. (Such as alimony, unemployment or retirement benefits.)
Provide documentation such as court orders or loss of benefits notification.
F _____ Loss of support from parent or spouse due to separation, divorce, or death.
Provide court papers for separation or divorce or a death certificate, and copies of W-2 forms from student, parent or spouse.
STEP 2: Submit a typewritten statement, signed by the student, describing your (or your parent’s, if applicable) loss-of-income
situation in as much detail as possible.
STEP 3: Estimate your (the student’s) total income from all sources for ALL of 2019 (1/1/19 to 12/31/19) or 2020 (1/1/20 –
12/31/20) including year-to-date PLUS estimated future 2019 or 2020 (as appropriate) income including wages from your
current job, unemployment benefits, income from any kind of disability, retirement income, alimony, child support received plus all
other taxable and untaxed income for 2019 or 2020.
Income Year (Check One): ___ 2019 ___ 2020
$_____________________ (Do not leave this line blank. Write N/A if not applicable.)
STEP 4: Estimate your parent’s total income from all sources for ALL of 2019 (1/1/19 to 12/31/19) or 2020 (1/1/20 –
12/31/20) including year-to-date PLUS estimated future 2019 or 2020 (as appropriate) income including wages from your
current job, unemployment benefits, income from any kind of disability, retirement income, alimony, child support received plus all
other taxable and untaxed income for 2019 or 2020.
Income Year (Check One): ___ 2019 ___ 2020
$_____________________ (Do not leave this line blank. Write N/A if not applicable.)
STEP 5: Estimate your spouse’s total income from all sources for ALL of 2019 (1/1/19 to 12/31/19) or 2020 (1/1/20 –
12/31/20) including year-to-date PLUS estimated future 2019 or 2020 (as appropriate) income including wages from your
current job, unemployment benefits, income from any kind of disability, retirement income, alimony, child support received plus all
other taxable and untaxed income for 2019 or 2020.
Income Year (Check One): ___ 2019 ___ 2020
$_____________________ (Do not leave this line blank. Write N/A if not applicable.)
**CONTINUED ON THE BAC
KSIDE**
