Appeal for Re-evaluation of
615 N Stadium Ave, Thatcher, AZ 85552
Name: SS#/EAC ID#
Mailing Address:
City State Zip
Telephone # ( ) - Email: @
The purpose of this appeal form is to request an adjustment to either the Expected Family Contribution (EFC)
which resulted from your FAFSA or an increase in your Cost of Attendance (COA) budget. Read the options
carefully and complete only those items applicable to your circumstances. The formula for calculating financial
need is: COA EFC = NEED
I. The purpose of your appeal is to:
Report a change in earnings and/or financial resources due to unemployment, divorce, death of provider,
change in employment, or receipt of nonrecurring income. (The income used on your FAFSA was from 2019).
Proceed to Section II.
Request a revision to my cost of attendance due to unusual medical, dental, elementary or secondary private
tuition, exceptional transportation costs, dependent care, or computer purchase. In certain circumstances
exceptional expenses may also be deducted from the individual’s adjusted gross income.
Proceed to Section III.
II. The income reported on my Application for Federal Student Aid (FAFSA) does not accurately reflect my, my
spouse, my father or my mother’s (circle one) ability to pay for my educational expenses.
1. Whose income will be less in 2020, 2021 or 2022 (circle applicable year)? Mine, my spouse, my father, my
mother, (circle only one). If more than one persons income has changed, a separate appeals form is
required for each individual for whom an adjustment is requested.
2. Check the appropriate reason the individual’s income, circled in the previous question (Section II-1),
and as reported on the FAFSA, does not accurately reflect ability to pay.
A. Unemployment, change in employment resulting in less income, or reduced work hours.
B. Divorce/Separation.
C. Death of student’s spouse or parent.
D. Disability of student/student’s spouse, or parent.
E. One-time income such as severance pay, inheritance, back pay, IRA withdrawal, etc.
3. If 2 (A) or (D) is checked, provide the applicable information on income projection for the 2020, 2021 or 2022
tax year. Darken the oval below to indicate which documents are being attached. In addition to the documents,
write a statement of explanation regarding what you are requesting and why.
Income from wages, salaries, tips (including severance pay, disability payments, and any income from work.
Provide copy of last pay stub and documentation of reason for the change such as retirement, termination, etc.
Unemployment Benefits please provide evidence of receipt of or denial of benefits.
Social Security or SSI benefits please provide evidence of termination or denial of benefits.
Workforce services benefits. Please provide evidence of expected benefits.
Child Support, please provide documentation of expected decrease in payments.
Other income, please provide documentation of any other expected income.
If 2 (B) is checked, please attach verification of your income or the individuals income that has or will provide the
majority of your support during the academic year 2021-2022, i.e. W-2 forms.
If 2 (C) is checked; please provide verification of your or your surviving parent’s 2019 year income, i.e. W-2 Forms, Social
Security statements, etc.
If 2 (E) is checked, please identify in an attachment, the source of 2019 income, the amount, and how funds were spent or
invested. Example: Received IRA early withdrawal of $10,000 which was counted in 2019 adjusted gross income. This is
time income and it was spent to pay down house mortgage. Provide documentation of severance and mortgage
III. I/my spouse or family has educational expenses in the 2021-2022 academic years that are not accurately reflected in
the determination of my Expected Family Contribution or Cost of Attendance Budget. Check the statement that applies.
Medical, prescription and/or dental expenses: Please provide a statement explaining your/spouses / parents unusual
medical/dental expenses. Provide documentation to support this statement. Only out-of-pocket paid expenses will be considered. If
payments, provide a copy of your payment contract. Summarize all expenses on a spreadsheet.
Elementary and Secondary Private School educational tuition expenses: Please provide receipts for tuition and an
explanation as to who it is for and their relationship to you.
Dependent Care expenses: Please provide an attached statement indicating for whom the dependent care is provided,
their relationship to you, the days and times dependent care is required. A signed receipt or billing statement is also required
from the dependent care provided. Dependent care paid for by another agency cannot be considered.
Transportation expenses exceed those allowed in the student budget: please provide a statement explaining why your
transportation budget needs to be increased. If you travel long distances each day indicate where you live and how many
times you drive this distance each week. If you must purchase airline tickets, please indicate how many times you will be
making this one way trip and document the cost by printing a price quote from the internet.
Purchase of personal computer which is required for educational purposes: An invoice of the desired computer and software
must be attached. Student budgets can
only be increased once at EAC for the purpose of purchasing a personal computer.
IV. Certification:
All of the information on these forms is true and complete to the best of my knowledge. If asked, I will submit additional
proof to verify the information provided. I understand that if I do not provide this information, my request will not be
processed. I understand that submission of false information may result in a delay or denial of financial aid and may subject
me to referral to the Office of Inspector General.
Students signature: Date:
Parents signature: Date: