Fillable Office of Student Financial Aid Independent Status Appeal (North Carolina A&T State University)

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Office of Student Financial Aid Independent Status Appeal (North Carolina A&T State University)

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Office of Student Financial Aid
Independent Status Appeal Form 2021-2022
Students classified as dependent may petition to be reclassified as an independent student based upon documented
extenuating family circumstances. Examples of extenuating circumstances include estrangement from parents,
an unsafe home environment, or unknown whereabouts of your parents. Extenuating family circumstances do
not include financial hardship, a parent’s unwillingness to provide financial support or self-sufficiency
(living on your own). Documentation is required to support your request.
Deadline to submit application: March 27, 2022. During peak periods, the estimated timeframe for a
review is 6 to 8 weeks.
PLEASE PRINT
XXX
Student Last Name First Name MI Banner ID Last 6 Digits Only
Street City State Zip
E-Mail Address Telephone Number
SECTION A: New Independent Appeal
I am submitting the Independent Appeal Form and documentation for initial consideration during the
2021-2022 academic year.
Each applicant must provide detailed explanation of your circumstance and include the following:
• Provide a statement indicating the whereabouts of your biological parents.
• Describe the last time you had contact with each of your parents: when, where and the nature of the
contact.
• Explain why you cannot obtain parental information.
• If parent (s) is deceased, please provide copy of parent death certificate and copy of student’s birth
certificate
• Provide statements from three adults who are aware of your situation and can support the information that
you provide. Two of the three statements may come from the following:
Teacher/Professor Attorney
Guidance Counselor Psychiatrist/Health Personal
Social Worker Clergy
Court/Public Agency Family/Friend
Other
** ALL STATEMENTS FROM A 3
RD
PARTY MUST INCLUDE NAME, ADDRESS, PHONE NUMBER,
RELATIONSHIP TO THE STUDENT AND A SIGNATURE**
• Provide a copy of your 2019 Federal Tax Transcript or signed Tax Return (if you did not complete the
IRS data retrieval) and copies of your W-2, or verification of your income
• Complete and submit a 2021-2022 Verification Worksheet
• Verification of your current living arrangements (See page 2).
SECTION B: RENEWAL Independent Appeal
Please check one of the following boxes:
My Independent Appeal was approved in a prior academic year. However, Federal Regulations require
me to submit a statement verifying that the documented adverse family circumstances still exist.
Please provide the following:
A let
ter from at least two individuals and yourself stating your current relationship with your biological
parents for the past 12 months. The statements must come from one of the following:
Teacher/Professor Attorney
Guidance Counselor Psychiatrist/Health Personal
Social Worker Clergy
Court/Public Agency Family/Friend
Other
*
* ALL STATEMENTS MUST INCLUDE NAME, ADDRESS, PHONE NUMBER, RELATIONSHIP
TO THE STUDENT AND A SIGNATURE AND CANNOT BE THE SAME LETTER SUBMITTED
FROM A PREVIOUS YEAR**
Provide the following:
• 2019 Federal Tax Transcript or signed Tax Return (if you did not complete the IRS data retrieval) and
copies of your W-2, or verification of your income.
• Co
mplete and submit a 2021-2022 Verification Worksheet.
Section B: Explanation of your circumstance
Please explain in detail the extenuating family circumstances that you believe warrant review of your dependency
status. If additional space is needed, please attach a separate sheet. Do not leave this section blank.
Section C: Verification of Current Living Arrangements
On Campus Off Campus with Parent Where did you live in 2019? State
Where did you live in 2020? State
On Campus Off Campus with Parent
Cir
cumstances that DO Not Warrant an approval for an Independent Appeal
• Parents refuse to contribute to educational costs
• Parents unwilling to provide information on FAFSA or for the verification process
• Parents did not claim the student as a dependent for information for income tax purposes
• Parents income too high to qualify for need-based aid
• Student demonstrated total self-sufficiency.
Student Certification – Read carefully before you sign.
I hereby certify that all information contain in this document, including the documentation is true and complete. I affirm
that I have not knowingly provided any false statements or fraudulent documentation. I understand that if I am found
to have knowingly or intentionally given false or fraudulent statements and/or documentation, my eligibility for Federal
and State student aid may be jeopardized.
I understand that if I DO NOT provide supporting documentation, no further action will be taken on this request by the
Office of Student Financial Aid.
I understand approval in a prior academic year does not guarantee approval for the current academic year.
Note: Federal regulations stipulate that evidence of fraud must be reported to the U.S. Department of Education for
possible investigation by the Office of the Inspector General and possible prosecution by the United States Attorney
General’s Office.
NOTE: You are required to provide all documentation to support your request. Failure to
submit documentation may result in your request automatically being denied.
XXX
Print Name of Student Banner ID Last 6 Digits Only
Signature of Student
Mail or Fax completed form to:
North Carolina Agricultural and Technical State University
Office of Student Financial Aid
1601 E. Market Street
Greensboro, North Carolina 27411
Telephone: 336-334-7973 Fax: 336-334-7954
I
NDEP
21/22
REVISED: 12/20
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Office of Student Financial Aid Independent Status Appeal (North Carolina A&T State University)

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Completed 1 February 2021

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