Office of Financial Aid
323 Erie Street, P.O. Box 5015, Port Huron, Michigan 48061-5015
810-989-5530 fax 810-989-5774
Request for additional Financial Assistance due to unusual circumstances
(This form is to be used for additional funds, not for special circumstance requiring corrections to the FAFSA form)
Semester Today’s Date Program of Study
Student Last Name Student First Name Student ID #
Student Address Phone #
Description of Unusual Circumstance:
Itemization of costs:
Total cost of tuition & fees $
Total cost of books $
Total cost of miscellaneous fees $
(Less) Other Financial Aid $
(Less) Payment from student $
Amount of Funds Requested $
Office Use Only
Approved ________ Award Amt $ ___________ Award Code/Name _________ ______________________________
Award Amt $____________ Award Code/Name _________ ______________________________
Total Award $____________
Denied ________ Reason__________________________________________________________________________