Per Federal Guidelines, SUNY Orange is required to review your enrollment history based on the results of your
FAFSA application.
Student Name Student ID# A
Section #1 - Schools Attended
* You must provide the following information for each school you attended during the time frame
listed.
* If you attended multiple schools during the indicated time frame, attach a separate piece of paper
listing all schools you attended.
* You MUST attach an academic transcript from each school you have attended.
* Your file will not be reviewed until all transcripts are received with this form.
* If you fail to report a school that you attended during the indicated time frame or fail to attach a
transcript, you may be denied financial aid at SUNY Orange.
Name of Schools (s) Year Attended Academic Credits Earned?
2012 - 2013
2013 - 2014
2014 - 2015
Yes
Yes
Yes
No
No
No
Section #2 - Extenuating Circumstances
If you have extenuating circumstances that prohibited you from earning academic credit, detail your circumstances
below. You MUST include third party documentation to substantiate your claim.
Death of an immediate family member (must include the relationship of family member to the student, copy of
death certificate)
Military Obligations (must include documentation from commanding officer)
Victim of a crime or unexpected disaster (must include copy of police report, third party letters, etc.)
Other (must include appropriate documentation)
I certify that the information reported on this form is true and correct. If requested, I agree to provide additional
documentation to the Financial Aid Office.
Student Signature Date
115 South Street * Middletown, NY 10940 * phone (845)341-4190 * fax (845)341-4194
1 Washington Center * Newburgh, NY 12550 * phone (845) 562-2454 * fax (845) 220-4062
www.sunyorange.edu
Documented hospitalization or illness of self, child or parent (must include dates and a health care provider's
decision, written on official letterhead, as to the student's readiness to return to school)
UEH
1415
