1Office of Student Financial Aid Lamar State College Port Arthur
MEMBER THE TEXAS STATE UNIVERSITY SYSTEM
TM
PLSC_APPEAL FORMS_S
SPECIAL CIRCUMSTANCES FORM 20192020
Student’s Name __________________________________________ Student ID _________________________
This form may be used for the 2019-2020 academic year if the financial situation used in the completion of your Free Application for Federal Student
Aid (FAFSA) has changed or if you had unusual circumstances occur in 2018 or 2019.
Check all that apply.
If you are an INDEPENDENT student: If you are a DEPENDENT student:
1.Loss of employment or change of employment status 7.You or your parents’ loss of employment or change of
for you or your spouse for at least 10 weeks. employment status for at least 10 weeks.
2.Divorce/separation or death of your spouse.* 8.Divorce/separation or death of a parent.*
3.Loss of untaxed income (Social Security benefits, 9.Loss of untaxed income (Social Security benefits,
pension, etc.)* pension, etc.)*
4.Disability of you or your spouse. 10.Disability of you or your parent.
5.Unusual medical or dental bills or handicapped- 11.Unusual medical or dental bills or handicapped-
related expenses (7½% of adjusted gross income).* related expenses (7½% of adjusted gross income).*
6.Other unusual debt or expenses. 12.Other unusual debt or expenses.
*Adjustment to 2017 income (line item) *Adjustment to 2017 income (line item)
Adjustment To Income Chart - Please complete this chart for 2018 if you checked 1, 4, 7, or 10 above.
STUDENT OR SPOUSE
PARENT
Wages, salaries, severance pay
$
$
Other taxable income
$
$
Untaxed Social Security benefits
$
$
TANF/Welfare
$
$
Child Support
$
$
Other untaxed income
$
$
Unemployment benefits to be received
$
$
Total income
$
$
Adjusted Gross Income
$
$
Taxes paid
$
$
EIC
$
$
Certification:
I hereby certify that all information contained in this appeal, including the personal statement and documentation, is true and complete to the best of
my knowledge.
I understand that it is my responsibility to pay all outstanding balances on my account while waiting for an appeal decision. Regardless of the appeal
decision, I am responsible for any late fees incurred. My appeal will not be reviewed until all documentation has been received. I will receive an
email notifying me once it has been reviewed.
___________________________________________________________ ______________________
Student’s Signature Date
__________________________________________________________ ______________________
Parent or Spouse’s Signature (if applicable) Date
Attach Required Documentation. (See reverse side of this form for required documentation.) OVER
For office use only: Approved Rejected
Financial Aid Officer: Date:
REQUIRED DOCUMENTATION FOR SPECIAL CIRCUMSTANCES
Typed a detailed cover letter explaining the circumstances. (Not to exceed 250 words)
DOCUMENTATION THAT WILL PROVIDE A “SNAPSHOT” OF YOUR 2018 FINANCIAL POSITION
Loss of employment or change in employment status
Letters from prior employers, stating termination/layoff dates on letterhead, signed, dated and includes title/position
and telephone number.
If you are currently employed, a copy of the last pay statement for 2019 from your current employer indicating
employment start date and yearto-date earnings.
Copy of 2018 Tax Return Transcript, W2’s and/or 1099s
Unemployment recap showing amount of benefits received and expected unemployment received in 2018/2019 OR
notarized statement indicating no benefits received in 2018.*
Documentation of any severance pay received, IRA’s, stocks, bonds, pensions, etc. converted to cash.
*Required for student and parent(s) if dependentrequired for student/spouse if independent.
We cannot adjust for a loss of overtime or if you are self-employed.
Divorce or separation of student or parent
Divorce copy of divorce decree (certified)
Separation copy of the legal separation document; a signed statement from your attorney, showing the date of
separation; or two notarized statements from an unrelated third party and documentation showing two (2) separate
households.
Death of a spouse or parent
A death certificate
Loss of untaxed income
A copy of a letter from the agency that provided benefits, detailing termination of benefits, and copies of
Summaries of benefits.
Disability of student or spouse or parent
Medical documentation of disability and of any benefits received as a result of the disability.*
Income from all sources in 2018.*
*Required for student and parent(s) if dependent required for student/spouse if independent.
Unusual medical or dental bills or handicapped-related expenses
A copy of Schedule A of the Federal Tax Transcript or canceled checks or receipts showing amount paid with
statement from insurance company showing expenses were not reimbursed.
Other unusual circumstance not covered above
Explanation and documentation
ATTACH REQUIRED DOCUMENTATION TO COMPLETED FORM,
AND RETURN TO THE OFFICE OF STUDENT FINANCIAL AID, APPLICATION WILL ONLY BE
REVIEWED ONCE. MAKE SURE YOU TURN IN PROPER DOCUMENTATION
.
VERIFICATION TAKES ABOUT 2 WEEKS DURING PEAK TIME.
YOU WILL BE NOTIFIED BY E-MAIL OF THE DECISION OR IF ANY ADDITIONAL INFORMATION IS
NEEDED
.