REQUEST FOR INDEPENDENT STATUS
(2020-2021 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 firstname.lastname@example.org
Required Documentation for Extreme or Extenuating Circumstances:
Under extreme or extenuating circumstances the Office of Student Financial Aid may review the dependent status for
students. If you have extreme or extenuating circumstances, you MUST complete the following required
documentation, failure to submit the documentation will result in a denial:
Personal letter of explanation regarding how you came to support yourself and the time period you have done
this. Describe the events in your family, which led to your current separation from them. If you are receiving
support from friends or relatives, describe the nature of that support (monies received; housing; food; clothing;
etc.) and who provides the support. Provide any and all information, which you feel will help to outline your
Signed and dated letter from a professional (clergy, counselor, teacher, etc.) that can document your extreme or
unusual circumstances. This letter should be on letterhead from the individual’s employment along with contact
information. A letter from a friend or family member is not acceptable.
Copies of all applicable court, police or legal documentation pertaining to your circumstance.
Renewal of Dependency Override (ONLY for students who have previously been approved at CCC):
If you received financial aid as an Independent student at CCC based on an appeal submitted previously, you are
required to resubmit an appeal each academic year. The circumstances under which you were granted independency
must be reaffirmed. Please check the appropriate box and provide required documentation.
The special circumstances under which I was granted Independency status in 2019-2020 have not changed.
Provide any documentation that updates and/or reaffirms your situation.
My circumstances have changed. Please attach documentation of changes along with a personal letter of
explanation. Attach any documentation which updates your status. You may be asked to provide additional
Allow 10 working days after an appeal is submitted before a decision is made. If a decision has not been made
on your appeal by drop for non-payment date, you must make payment or sign up for the College Payment Plan;
otherwise your classes will be dropped for non-payment.
I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand that submission of false
information may result in a delay or denial of federal financial aid and may subject me to criminal charges. I understand that purposely giving
false or misleading information may result in a fine of up to $20,000, being sent to prison, or both. I understand that if I do not give proof when
asked, this request will not be processed. I hereby provide consent for the use of electronic records and signatures on all financial aid
documents. I understand that if I choose to sign electronically, my electronic signature constitutes a binding contract and may not be denied
legal effect, validity, or enforceability solely because it is in electronic form or because an electronic signature or electronic record was used
in its formation.
Student’s Signature and Date How do I create a digital signature with Adobe?
For OSFA Use Only:
Prior year special conditions: Yes No If “Yes,” request documentation of 2018 income.
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