Lost Eligibility Worksheet and Waiver Request Form

Waivers that are turned in after ___________________________ will not be processed in time to be used as a deferral towards tuition and fees.

You will be responsible for payment after this date.

Instructions:

— Fill out page two – Lost Eligibility Worksheet by completing your name, SS# and Banner ID.  Choose the appropriate explanation.  If none of these reasons applies to your situation, a waiver probably WILL NOT be granted.  Keep in mind that some options require documentation or an explanation of the circumstances.  Waivers requiring documentation are only granted for circumstances beyond the student's control.  Please note: leaving school or dropping classes in order to work is not grounds for a waiver.  You cannot use the same reason for more than one waiver except for reason #5.

— Fill out page three – Waiver Request Form by completing name, SS# and Banner ID, address, whether it is for State or Federal Aid and sign the waiver.

— Fill out page four – Authorization for Release of Health Records only if there was a medical reason.  Give this page to your medical provider to complete and return to our office.

— After you have completed pages two and three (and page four if applicable) make an appointment with a Student Development Counselor to review and sign your Waiver Request Form.  Waivers will not be processed without a signature from their office.

— If Student Development signs your Waiver Request Form, return all pages to the Financial Aid Office for approval.  You will be able to check the status of your waiver by logging in to your Banner account.  It takes five to seven days to receive notification.

A waiver may be granted only once for any particular situation.

Please Note:  If none of the reasons on page two applies to your situation,

a waiver probably WILL NOT be granted.

Lost Eligibility Worksheet

To be returned to Financial Aid

Name ______________________________________________     SS#______________________________

Banner ID# _________________________________

Ø  Check the appropriate explanation. If none of these reasons applies to your situation, a waiver probably WILL NOT be granted.   Please note:  You cannot use the same reason for more than one waiver except

for reason #5. 

Ø  NOTE: Leaving school or dropping classes in order to work is not grounds for a waiver. 

Ø  Waivers requiring documentation are only granted for circumstances beyond the student's control.

Ø  A waiver may be granted only once for any particular situation.

Ø  If you have questions on completing this form, contact the Financial Aid Office at (315) 255-1743 ext. 2470.

Federal and/or State Aid

1. ____ I withdrew from a semester (or some classes) at Cayuga Community College within the

        last year due to illness, accident or death in the family.

REQUIRES DOCUMENTATION:   For illness or accident, have your physician complete the

enclosed confirmation form.  Do not submit actual medical records.  For a death in the family,

attach a death certificate or copy of the obituary along with an explanation of your relationship

 to the deceased.  Waivers for extenuating circumstances will not be granted for consecutive

semesters.

2.     ____ I was a student at CCC over a year ago with a poor academic record and now realize the

         importance of a college education.

NOTE: Two (2) full semesters must have passed since your last attendance.

                        Write a letter explaining the circumstances of your withdrawal from CCC and what has

changed to make you believe you can now be successful.

Federal Aid ONLY

3.     ____  Other extenuating circumstances beyond the student's control.

   REQUIRES OFFICIAL DOCUMENTATION from a source other than the student.

  The documentation must prove that (1) the situation occurred and (2) that it is unlikely to recur.

  Waivers for extenuating circumstances will not be granted for consecutive semesters.

4.    ____   I am in a second degree program that has been approved by the Student Development Office.

                  (Note:  Current degree evaluation must be attached).  Generally there is a 2 semester maximum for

                  completing a second degree.

5.    ____   I previously attended CCC without successfully completing the required number of credits.  However,

I have just completed a semester of 6 credits or more with a 2.0 GPA, no withdrawals and no F's.

(Attach grade report from prior semester).

Waiver Request Form

New York State and Federal Student Financial Aid

Before completing the Waiver Request Form, a student should read and complete the Lost Eligibility Worksheet.

To be completed by student:

   Name __________________________________________________________

   Social Security # _______________________________   Banner ID # _________________________

   Address ______________________________________   Phone # ____________________________

   City _____________________________   State ___________     Zip code ______________________

I request a waiver for:             ________  State Aid               ________  Federal Aid

I understand that a waiver may be granted only once for New York State awards and only twice for Federal awards.  I also recognize that at the end of the semester for which the waiver is granted:

1.      I must fulfill the minimum standards required for continued receipt of financial aid or

2.      I may apply for an extension of my waiver if I was registered for 6 or more credits and completed all credits, (no F's, or W's), with a 2.0 GPA or higher.

Student Signature _______________________________________________         Date ______________

To Be Completed by Student Development Counselor

I have reviewed this waiver request.  Based upon the documentation provided (if required) and my evaluation of this student's potential for academic success, I recommend:

            Approval _______                 Disapproval _______    of this request.

Counselor Signature _____________________________________________         Date ______________

To be Completed by the Director of Financial Aid

Based on the documentation provided and the counselor recommendation, this request is:

            Federal:   Approved _____   Denied _____                         State:   Approved _____   Denied _____

            Comments and conditions ______________________________________________________________

            ____________________________________________________________________________________

            Date____________________________

Authorization for Release of Health Records

(To be completed by student)

Student Name ______________________________________        Social Security # _________________

Banner ID # __________________________________

Student Signature ______________________________________________           Date ______________

---------------------------------------------------------------------------------------------------------------------------------------

Confirmation of illness/accident

(To be completed by your physician)

I certify that ___________________________________________________________ was treated by me

from (date) _____________________________ to ______________________________ due to illness,

accident or complications of pregnancy.  (NOTE: normal pregnancy should not be included.)

Please check both if they apply:

_______  During this period of time the student was unable to attend classes.

_______  The student is now able to return to classes.

Additional Comments _____________________________________________________________________________________

_____________________________________________________________________________________

Physician signature _______________________________________________________

Physician printed name ____________________________________________________

Physician phone number ___________________________________________________

Date ___________________________________________________________