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

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Office of Student Financial Aid Special Circumstances Appeal (North Carolina A&T State University)

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Office of Student Financial Aid
Special Circumstances Appeal 2019-2020
Please allow up to 30 days for this form to be processed
Deadline to submit form is April 1, 2020
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.
XXX
Student’s Name Banner ID
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.
• Submit a completed 2019-2020 Verification Worksheet;
• Provide copy of 2017 and 2018 tax return transcript and copies of all 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.
2018 INCOME ESTIMATION TABLE January 1, 2019– December 31, 2019
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 2019-2020 Verification Worksheet;
• If joint tax return was filed, attach copies of 2017 and 2018 tax return transcript or 2017 and 2018 signed
tax return and copies of all W-2’s and supporting schedules.
Section C- Medical Expenses – (Unreimbursed expenses only)
Submit a complete Federal 2017 and 2018 IRS tax transcript or a copy of your 2017 and 2018 signed tax return, a copy of
Schedule A and all W-2’s. Submit a completed 2019-2020 Verification Worksheet. If deductions were not itemized,
complete the table below and attach documentation showing total checks or receipts paid by you in 2017. 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
(out–of-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 underestimating projected income may result in reduced aid eligibility, repayment of aid, or both, in this year and/or the next year.
I also 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: 04/19
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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Office of Student Financial Aid Special Circumstances Appeal (North Carolina A&T State University)

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Completed 23 July 2020

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