2023-2024 Academic Year
Change in Circumstances Appeal (Independent)



Reminders:

If you are married, you must provide wage and tax information for you and your spouse.

For appeals based on loss of income, we compare the tax year used on the FAFSA to the current years income earned to date along with the projected income for the remainder of the year.

The tax year used on the 2023-2024 FAFSA is tax year 2021. To process your request, you must include a signed copy of this tax return not your 2022 taxes! If your tax return does not include the signature of at least one of the tax filers nor the preparer’s certifications, it does not qualify as a ‘signed tax return’. Then tax filer’s signature or tax preparer information must be located in the portion of the tax return shown below.


Student Name*
1. Personal Statement: a signed statement detailing your circumstance and a timeline for the events that occurred. *
No File Chosen
File uploads may not work on some mobile devices.

2. Reason for Appeal: indicate the circumstance you would like us to consider and upload all required documents

REASON FOR APPEAL*
A copy of the last pay statement showing gross year-to-date income for all jobs worked for both student and spouse (if applicable) *If more than one employer, please include start/end dates in written statement.
No File Chosen
File uploads may not work on some mobile devices.
Notice of cancellation or reduction of benefits/income and effective date*
No File Chosen
File uploads may not work on some mobile devices.
List medical expenses not covered by insurance and dates of event *
No File Chosen
File uploads may not work on some mobile devices.
Receipts and/or billing statements from medical provider(s) that the family or student has paid out of pocket*
No File Chosen
File uploads may not work on some mobile devices.
Itemized statement from insurance company documenting costs not covered by insurance*
No File Chosen
File uploads may not work on some mobile devices.
Divorce decree or separation agreement (If legal documentation doesn’t exist, submit a signed statement indicating date of separation AND two forms of documentation showing proof of separate residences i.e. lease, mortgage statement, utility bill, driver’s license, etc.). *
No File Chosen
File uploads may not work on some mobile devices.
Death certificate*
No File Chosen
File uploads may not work on some mobile devices.
Copies of insurance policy/statements that documents deductibles or unreimbursed expenses*
No File Chosen
File uploads may not work on some mobile devices.
FEMA application, detailed contractor quotes, invoices, and/or receipts.*
No File Chosen
File uploads may not work on some mobile devices.
Provide receipts, paid bills, etc. documenting how funds were used. (Payments towards consumer debt will not be considered). *
No File Chosen
File uploads may not work on some mobile devices.
IRS Form 5329 which shows the withdrawal was due to an economic hardship.*
No File Chosen
File uploads may not work on some mobile devices.
Documentation of expected survivor benefits (life insurance, death-benefits, annuities, pensions, etc.)
No File Chosen
File uploads may not work on some mobile devices.
Agreement of financial support payments (e.g. alimony, spousal support, child support or dependent care)
No File Chosen
File uploads may not work on some mobile devices.
Signed copy of the 2021 federal income tax return AND W-2 forms for both student and spouse listed on the FAFSA* (Do not provide other tax years!).*
No File Chosen
File uploads may not work on some mobile devices.
Documentation of pension and/or monthly social security benefits
No File Chosen
File uploads may not work on some mobile devices.
A copy of the last pay statement showing gross year-to-date income
No File Chosen
File uploads may not work on some mobile devices.
Documentation of last date of employment*
No File Chosen
File uploads may not work on some mobile devices.
Documentation from employer verifying loss/change of employment including effective date*
No File Chosen
File uploads may not work on some mobile devices.
Documentation of unemployment benefits (federal and state)
No File Chosen
File uploads may not work on some mobile devices.
Documentation of severance pay received, or IRA’s, stocks, bonds, pensions, etc. converted to cash
No File Chosen
File uploads may not work on some mobile devices.
Signed copy of the student and spouses (if applicable) 2021 federal income tax return (Do not provide other tax years!).*
No File Chosen
File uploads may not work on some mobile devices.
Additional Supporting Documents*
No File Chosen
File uploads may not work on some mobile devices.
Additional Supporting Documents
No File Chosen
File uploads may not work on some mobile devices.

3. Household Size: List the people in your household. Include,

  • Yourself
  • Your Spouse
  • Your children if you will provide more than 50% of their support from July 1, 2023 – June 30, 2024
  • Other people who live with you and you will provide more than 50% of their support
  • Include the name of the college for any household member who will be enrolled at least half-time between July 1, 2023 and June 30, 2024.
Full Name*

4. Actual and Estimated 2023 Calendar Year Taxed and Untaxed Income (Enter "0" if not applicable). 

The First column on the left should include gross income (before deductions) earned to date. The second column is an estimation of the gross income for the remainder of the calendar year. The final column is the sum of column one and two.

Taxable Income:

Jan 1 – Today, 2023

Remainder of 2023

Total

Income earned from work-Student

$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total

Income earned from work-Spouse

$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total

Business Income

$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total

Unemployment Compensation (Federal and State)

$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total
Other (enter source)
$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total
Other (enter source)
$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total

Untaxed Income: 

INCLUDE: Workman’s compensation, disability payments, alimony, housing, food & living allowances, cash or any money paid on your behalf

Veteran’s Non-Education Benefits

$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total

Child Support Received

$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total

Tax Deductible Payments to IRA/Keogh

$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total
Other
$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total
Other
$
Actual Amount Year to Date
$
(+) Estimated Amount
$
(=) Total
Student Certification*
Type Student Name
Use your mouse or finger to draw your signature above
Date
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