' '
' '
'
!
! !
! ! !
! ! !
! ! !
! ! ! ! !
Student Services
Financial Aid' Office
2020-2021
Professional Judgment Appeal for Special Circumstances Form
Award Year
__________ Date ____________
Student Name User Name/Student ID
Parent(s) Name________________________________________________________________________
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
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 Title IX Coordinator, 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
2020-2021
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 Title IX Coordinator, 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
2020-2021
Income Table
INCOME FOR JANUARY 1, 2020
TO DECEMBER 31, 2020
ACTUAL
01-01-2020 - Today
ESTIMATED
Today to 12-31-2020
TOTAL
Actual + Estimated
Student 2020 gross income earned from work
(wages, salaries, tips, etc.)
$
$
$
Parent(s)/Spouse 2020 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 2020
$
$
$
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 (D
ependent 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 Title IX Coordinator, 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
click to sign
signature
click to edit
click to sign
signature
click to edit