CAYUGA COMMUNITY COLLEGE

Financial Aid Office · Auburn 315-255-1743 ext. 2470 · Fulton 315-592-4143 ext. 3004 · FAX 315-252-2185

Student Appeal for Additional Assistance

(Do not file this form prior to July 1, 2012)

Name

Cayuga ID Number C

The Financial Aid Office at Cayuga Community College realizes that students and their families experience unforeseen circumstances and/or loss of income during an academic year. This form is designed to address your possible need for additional funding as a result of these unusual circumstances. Please complete all sections and submit the required documentation along with a 2011 IRS tax transcript and all 2011 W-2 forms. Forms submitted without sufficient documentation will be returned to the student. Please attach a letter to this form explaining why you are filing this appeal.

1. If your (or your parents’) marital status has changed, due to separation, divorce or death since you filed your application, please indicate the change. You must also attach supporting documentation to confirm the change. (i.e. Divorce or Separation Agreement, proof of separate mailing addresses, etc.) Please fill in the estimated 2012 income chart.

2. If you or your family have had extraordinary medical expenses in either 2011 or 2012, please enter the total unreimbursed medical expenses that have been paid out of pocket for all family members. Attach an explanation and any available documentation to verify these expenses.

Paid medical expenses minus reimbursement: $___________________________

3. If you or your parents expect sources of income to be lower in 2012 than in 2011 please fill out the estimated 2012 income chart. Do not leave any blanks. Enter “0” if appropriate. Please attach an explanation for your reduced income and any other unusual circumstances that you would like our office to consider when re-evaluating your aid application. You must provide supporting documentation, such as unemployment verification, letter of separation from your job, etc.

VOLUNTARY TERMINATION OF EMPLOYMENT WILL NOT BE CONSIDERED FOR AN APPEAL.

Note: If changes are made to your award based on estimated income, the Financial Aid office may request verification of 2012 income during the 2013 spring semester and may make revisions based on the accuracy of your estimates. Notification of the results of your appeal will be posted to your Cayuga account.

(over)

ESTIMATED 2012 INCOME	MOTHER	FATHER	STUDENT	SPOUSE
TAXABLE Income	////////////	////////////	////////////	////////////
Wages, Salaries, Tips	$	$	$	$
Interest	$	$	$	$
Dividends	$	$	$	$
Unemployment	$	$	$	$
Distributions	$	$	$	$
Pensions	$	$	$	$
Alimony	$	$	$	$
Business/Farm Income or Loss	$	$	$	$
Rental Income or Loss	$	$	$	$
Other Taxable Income List source -	$	$	$	$
UNTAXABLE Income	////////////	////////////	////////////	////////////
Child Support	$	$	$	$
Disability, Workers Compensation	$	$	$	$
AFDC/ADC Other Welfare Benefits	$	$	$	$
Personal contributions to retirement accounts	$	$	$	$
Other Untaxed Income List source -	$	$	$	$

CERTIFICATION STATEMENT: The information provided on this form is true and complete to the best of my knowledge. I agree to provide additional documentation if requested. I further agree to notify the Cayuga Community College Financial Aid office of any change in the above information. I understand that failure to comply with this agreement could result in forfeiture of financial aid for the student.

______ I have enclosed a copy of my/my parents 2011 IRS Tax Transcript and all 2011 W-2 forms.

_________________________________________________ __________________________________________________

Student Signature Date Parent Signature (if applicable) Date

Please return this form to the Financial Aid Office at Cayuga Community College

197 Franklin St., Auburn, NY 13021-3099.

Results of Appeal ______________________________________________________________________

FAA Signature _______________________________________________________ Date _________________________

tr rev. 1/12bpr (Appeals Form)