Student Services
Financial Aid Office
2019-2020
Professional Judgment Appeal for Special Circumstances Form
Award Year __________ Date ____________
Student Name User Name/Student ID
Parent(s) Name_______________________________________________________________
Marital Status Change - to allow students/parent(s) to update their marital status if the school determines
the update is necessary to address an inequity or to reflect more accurately the student’s ability to pay.
**Additional Documents Required: 1) Student and Spouses most recent Tax Return Transcripts, 2) Dated
Marriage Certificate 3) Letter stating new number of family members who will be receiving at least 51%
support from the student/spouse
Parental Non-Disclosure- parent(s) refuse to provide required information to complete the FAFSA, do not
provide any financial support to the student, AND, will not provide support in the future. **Additional
Documents Required: 1) Signed/dated statement from parent(s) explaining in detail the circumstance for
not providing information on the FAFSA, why support has ended including the date, and confirming they
will not provide support in the future. OR, 2) Signed/dated statements from student, and an independent
third party such as counselor, teacher, pastor, court system, etc, explaining the situation as it relates to
the relationship with the parent(s) and the extenuating circumstance.
PLUS Loan Exceptional Factors - parent(s) are unable or unwilling to borrow a PLUS loan due to
exceptional factors. **Additional Documents Required: 1) Official documentation showing proof of one
of the following extenuating circumstances pertaining to the parent: Incarcerations, Bankruptcy
indicating parent(s) are unable to incur additional debt, Parent income is limited to public or federal
assistance or disability benefits, Parent is not a US citizen or permanent resident, but student is.
Loss of Income/Income Reduction (Check all that apply) - circumstances, such as a lost job or pay cut,
result in prior earnings that may not be an accurate representation of the annual recurring income. (Please
complete section A below)
Student/Spouse
Parent(s)
**Additional Documents Required: 1) Letter from former employer, on letterhead confirming
termination, reduction in hours, pay cut, etc, 2) w-2 Forms or pay statements showing year-to-date
income, 3) Unemployment compensation claim if applicable
Kaua’i Community College does not discriminate on the basis of age, race, sex, color, national origin, or disability in its programs and activities. For
more information or inquiries regarding these policies, please contact Teresa Tumbaga, Title IX Coordinator, tumbagat@hawaii.edu, 808-245-8395 or
Alicia Sams, Student Support Counselor, samsa@hawaii.edu, 808-245-8317.
3-1901 Kaumuali‘i Highway
Līhu‘e, Hawai‘i 96766-9500
Telephone: (808) 245-8360
Fax: (808) 245-0100
An Equal Opportunity/Affirmative Action Institution
Please indicate the reason for requesting professional judgment consideration for yourself. You must document the
reason for your request and submit this form along with any non-returnable copies of documents that support your
request, to the Financial Aid Office. Any requests submitted without signature, date or documentation will not be
considered.
Please complete, sign and submit this form with a letter of explanation and the required documentation to the Financial
Aid Office.
Reason for Request
________________________________________________________________________
_________
_______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Student Services
Financial Aid Office
2019-2020
One-time Taxable Income (Non-reoccurring income) - a portion of income is a one-time event;
therefore, earnings may not be an accurate representation of the annual recurring income. **Additional
Documents Required: 1) Dated documentation, from a third party, showing current years income to date.
Excessive Medical/Dental Expenses - medical or dental expenses that are medically necessary, not
covered by insurance, and paid, not owed by the student. **Additional Documents Required: 1)Receipts
from payments made, or 2) Copies of cancelled checks or other payment sources supporting that expenses
were paid but not covered by insurance, 3) Copies of insurance documentation supporting expenses that
were covered as compared to other documentation showing expenses not covered but paid, 4) Tax
Transcripts
Exceptional Expenses - unavoidable expenses, such an uninsured casualty losses, natural disaster-
related expenses, funerals, or excessive legal fees. **Additional Documents Required: 1) Copies of
cancelled checks or other payment sources supporting that expenses were paid but not covered by
insurance, and 2) Copies of insurance documentation supporting expenses that were covered as
compared to other documentation showing expenses not covered but paid
Selective Service - demonstrate, with evidence, that failure of male students 26 years old or older to
register was not knowing and willful. **Additional Documents Required: 1) Status information letter
from Selective Service, 2) Letter from the student explaining situation and why he/she was not aware of
the requirement, 3) supporting documentation if any of the following apply: Incarceration,
Hospitalization, Military service, recent citizenship status change, address changes
Parent(s) Enrolled in College -parent must be attending a Title-IV-eligible institution in a degree
seeking program with at least half-time enrollment status and must be paying his or her own tuition.
**Additional Documents Required: 1) Dated statement from the college verifying the degree seeking
program and number of credits the parent is enrolled in, 2) Copy of cancelled check or other proof of
payment to the institution for tuition.
Other Extenuating Circumstances:
Kaua’i Community College does not discriminate on the basis of age, race, sex, color, national origin, or disability in its programs and activities. For
more information or inquiries regarding these policies, please contact Teresa Tumbaga, Title IX Coordinator, tumbagat@hawaii.edu, 808-245-8395 or
Alicia Sams, Student Support Counselor, samsa@hawaii.edu, 808-245-8317.
3-1901 Kaumuali‘i Highway
Līhu‘e, Hawai‘i 96766-9500
Telephone: (808) 245-8360
Fax: (808) 245-0100
An Equal Opportunity/Affirmative Action Institution
Student Services
Financial Aid Office
2019-2020
Income Table
INCOME FOR JANUARY 1, 2019
TO DECEMBER 31, 2019
ACTUAL
01-01-2019 - Today
ESTIMATED
Today to 12-31-2019
TOTAL
Actual + Estimated
Student 2019 gross income earned from work
(wages, salaries, tips, etc.)
$ $ $
Parent(s)/Spouse 2019 gross income earned
from work (wages, salaries, tips, etc.)
$ $ $
Other taxable income: (enter in appropriate
line)
Dividends ………………………..
Interest …………………………..
Pensions …………………………
Annuities ………………………...
Alimony …………………………
Capital Gains …………………….
Unemployment Compensation …..
Rental …………………………
Partnerships………………………
S Corporations …………………...
Business/Farm Income ………..…
Combat Pay……………………
Other (specify what) ……………..
$
…………………
…………………
…………………
…………………
…………………
…………………
…………………
…………………
…………………
…………………
…………………
…………………
…………………
$
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
$
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
Child support received $ $ $
Other untaxed income:(enter on appropriate
line)
Workers Comp……………………
Payments to IRA/KEOGH………..
Tax Exempt Interest……………
Untaxed portions of pensions …….
Non-educational veterans benefits..
Untaxed disability from all sources
Housing and other allowances for
clergy or military……………..
Other (specify what) ……………...
$
…………………
…………………
…………………
…………………
…………………
…………………….
…………………
…………………
…………………
$
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
$
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
Total income for 2019 $ $ $
I certify that the information is true and correct to the best of my knowledge. I understand that any false statement or
misrepresentation may be cause for denial, reduction, or repayment of financial aid.
_______________________________________ _______________________________
Student’s Signature Date
_______________________________________ _______________________________
Parent Signature (Dependent Student) Date
Kaua’i Community College does not discriminate on the basis of age, race, sex, color, national origin, or disability in its programs and activities. For
more information or inquiries regarding these policies, please contact Teresa Tumbaga, Title IX Coordinator, tumbagat@hawaii.edu, 808-245-8395 or
Alicia Sams, Student Support Counselor, samsa@hawaii.edu, 808-245-8317.
3-1901 Kaumuali‘i Highway
Līhu‘e, Hawai‘i 96766-9500
Telephone: (808) 245-8360
Fax: (808) 245-0100
An Equal Opportunity/Affirmative Action Institution
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome