Office of Student Financial Aid
Special Circumstances Appeal 2020-2021
Please allow up to 30 days for this form to be processed
Deadline to submit form is April 1, 2021
This form is used to request special consideration for Federal Student Aid due to separation/divorce, death, loss of employment,
excessive medical expenses, loss of untaxed income or benefits, etc. Incomplete requests will not be considered. Approval does
not guarantee additional funding.
Banner: XXX ________
Student’s Name Last 6 digits only
________
Student Address City State Zip Code
( )
Student Email Address Student Telephone Number
***Place a check mark in appropriate box for your request***
Section A: Job Loss/Reduction in Income (Must be continuous for at least 3 months before appeal will be considered)
You are required to submit all the following information:
Provide a detailed letter (parent) or (student if independent) explaining the circumstances upon which you are
requesting for review. Include dates indicating when circumstances occurred.
Submit year-to-date earnings statement or copy of final paystub;
Submit a copy of most recent paystub if you, a parent or spouse is currently employed;
Submit documentation of unemployment, severance pay, disability or etc.
Provide copy of 2018 and 2019 tax return transcript or signed copy of Federal Tax Return along with W-
2’s.
Submit letter from employer indicating employee’s termination date and any payments or benefits received due to the
separation; and complete income estimation table below.
2020 INCOME ESTIMATION TABLE January 1, 2020December 31, 2020
Provide documentation or statement verifying how you arrived at the following figures
Income from work by student Amount: $_______________________
Income from work by student’s spouse Amount: $_______________________
Income from work by father/stepfather Amount: $_______________________
Income from work by mother/stepmother Amount: $_______________________
PROVIDE DOCUMENTATION
Other taxable income - List sources (i.e., unemployment compensation, disability benefits, interest and dividend income, alimony,
pensions, real estate income, capital gains/losses, and all other taxable income):
Source: ________________________ Amount: $_______________________
Source: ________________________ Amount: $_______________________
Source: ________________________ Amount: $_______________________
Total: $_______________________
PROVIDE DOCUMENTATION
Nontaxable income List sources (i.e., TANF, Social Security benefits, child support, and all other non-taxable income):
Source: ________________________ Amount: $________________________
Source: ________________________ Amount: $________________________
Source: ________________________ Amount: $________________________
Total: $________________________
Section B Divorce/Separation or Death:
A copy of divorce decree, death certificate, separation agreement, or obituary.
Provide a detailed letter (parent) or (student if independent) explaining the circumstances upon which you are
requesting for review. Include dates indicating when circumstance occurred.
Letter from appropriate State or Federal agency or other legal documentation specifying termination date
and amount of benefits received. Submit a completed 2020-2021 Verification Worksheet;
If joint tax return was filed, attach copies of 2018 and 2019 tax return transcript or 2018 and 2019 signed tax return and
copies of all W-2’s and supporting schedules.
Section C- Medical Expenses (Unreimbursed expenses only)
Submit a complete Federal 2018 and 2019 IRS tax transcript or a signed copy of your 2018 and 2019 tax return and all W-2’s.
Complete the table below and attach documentation showing total checks or receipts paid by you in 2018. We cannot consider
balances that have not been paid or paid by insurance.
Medical Expense Table
Name of Family Member
Month/Year Expenses
Incurred
Total Charge
Amount Paid by Family
(outof-pockets)
Example:
Jane Johnson
10/18
$5,000
$4,000
Total Amount of expenses Paid by Family $
Sign the Certification Statement below:
All the information on this Special Circumstances Appeal Form is true and complete to the best of my knowledge.
I understand that if I purposely give false or misleading information on this Appeal Form, I may be subject to a fine, a prison sentence or both.
If you are a dependent student, one parent must also sign. If you are a married student, your spouse must also sign.
___________________________________________ _________________________________________________
Student Date Parent Date
___________________________________________
Student’s Spouse Date
SPECIA
UPDATED: 11/19
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
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