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, 2020– December 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: $________________________
