Professional Judgment Request: Special and/or Unusual Circumstances

Professional Judgment Request

(For Special and/or Unusual Circumstances)
Date*

MonthDayYear
Today's Date
Student ID*
#900123456
Student Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
ASU Email*
student@adams.edu
Person Requesting Professional Judgment*
First and Last Name
Relationship to Student*

SelfParentGuardianSouseOther
Please Select Academic Year*
"Special Circumstances" and "Unusual Circumstances": What's the Difference?

Special Circumstances: refers to the current financial situation (i.e. loss of job, high medical expenses, etc.) of the student, parent, and/or student's spouse.

Unusual Circumstances: commonly referred to as a "Dependency Override". Refers to adjusting a student's dependency status based on a unique situation (i.e. incarceration, parental abandonment, human trafficking, refugee or asylee status, etc.).
Check which appeal you are submitting AND provide documentation to support your appeal below:

(Click "SUBMIT" when form is complete.)
Type of Appeal*

Special CircumstancesUnusual CircumstancesBoth
Check if the student, parent, and/or the student’s spouse experienced the above chosen appeal(s) - (Check all that apply):*

StudentParentSpouse (legally married students)
Year in which the Special and/or Unusual Circumstances occurred:*
Describe the Special and/or Unusual Circumstances in as much detail as possible:*
If appeal is for "Special Circumstances," please provide exact date loss of income or high medical expenses took place:

MonthDayYear
Date
If appeal is for "Special Circumstances," due to loss of income, please state previous income made and current income.
Required Documentation

Please attach as much documentation as possible that is relevant to your appeal
Check the boxes of the documentation you have included in your appeal:

Copies of your last (2) 1040 federal tax returns (2 pages) plus any schedules 1, 2, or 3. DO NOT attach any state tax returns.Last pay stub from past jobsMost recent pay stub from current employerRecent unemployment benefits documentation showing how much is being paidDocumentation of any kind of disability showing how much is being receivedDocumentation of ANY OTHER taxable or nontaxable income receivedPAID medical or dental expenses in excess of insurance coverage (must exceed 11% of Adjusted Gross Income)Itemized list of out-of-pocket expenses (see below)Other: Any documentation you feel would support your appeal
Provide an itemized list of out-of-pocket medical or dental expenses (if applicable):
- Do not list expenses covered by your insurance provider.
- Do not list any expenses that are not related to medical or dental expenses as they will not be considered.
Upload documentation files here*

Cancelof
Student Signature
I understand any false statements or misrepresentation will be reported to the Department of Education and may be cause for prosecution and denial, reduction, withdrawal, and/or repayment of financial aid.*

Clear
Student signature
Spouse or Parent Signature
Spouse or Parent Name

First NameLast Name
Relationship to Student

ParentSpouse
Spouse or Parent LAST Four Digits of Social Security Number (SSN)
Spouse or Parent Signature

Clear
Spouse or parent signature
By clicking the submit button below, I certify that all of the information reported on this form and any attachments are true, complete, and accurate to the best of my knowledge.

After form submission, please allow 2 to 3 weeks for processing. Further documentation may be required. Direct any inquiries to Jennifer Logacz at jenlogacz@adams.edu .
Should be Empty:

Professional Judgment Request

Check which appeal you are submitting AND provide documentation to support your appeal below:

Required Documentation

Student Signature

Spouse or Parent Signature