Unusual Enrollment History Review and Fax Coversheet

Transcription

1 Student Legal Last Name (print or type) First Name Middle Initial Student IRN Enrollment History: The University is required to review your prior enrollment history with regard to the receipt of Federal Pell Grant funds and/or Direct Loans. Based on the National Student Loan Data System (NSLDS) Pell Grant and/or Direct Loan award history and your academic transcripts or grade reports, it has been determined that you may not have earned academic credit or hours at each of your previously attended institutions. Applicable Award Year(s): Comment Codes (C codes) 359/360 populate on a student s Institutional Student Information Record (ISIR) when a review of the student s enrollment history is required. Please use the table below to determine the date ranges you must address. Submit this form with appropriate documentation as outlined below ISIR ISIR Award Years Date Ranges Award Years Date Ranges July 1, 2010 to June 30, July 1, 2011 to June 30, July 1, 2011 to June 30, July 1, 2012 to June 30, July 1, 2012 to June 30, July 1, 2013 to June 30, ISIR ISIR Award Years Date Ranges Award Years Date Ranges July 1, 2011 to June 30, July 1, 2011 to June 30, July 1, 2012 to June 30, July 1, 2012 to June 30, July 1, 2013 to June 30, July 1, 2013 to June 30, July 1, 2014 to June 30, July 1, 2014 to June 30, 2015 Page 1 of 7

2 Please review the information below, complete all sections, and submit supporting documentation as indicated. Supporting Documentation: The documentation submitted must support that academic credits or hours were earned or support the circumstance(s) you provide for not earning academic credits or hours, as well as correspond to your period(s) of enrollment at prior institution(s). Acceptable documentation includes, but is not limited to, the following: Evidence of academic credit or hours earned (or periods of enrollment for credit or hours not earned) Official transcripts Unofficial transcripts Grade reports Schedule/grades screenshots Third-party statements on official letterhead, signed and dated Physicians Counselors Law enforcement Legal counsel Social workers School administrators Note: Third-party statements from family and friends are not acceptable Official supporting documentation that verifies the circumstance(s) Medical records Obituaries Death certificates Legal documents/decrees Police reports Moving expenses Note: Official documentation to support this appeal is required. The University will not review an appeal if the required documentation is not provided. Page 2 of 7

3 Periods of Enrollment: Complete the table below in its entirety by listing the institutions and award years in which you received Federal Pell Grant funds and/or Direct Loan funds (the NSLDS report should be used as a reference). You can access your NSLDS report by visiting this site: (Also refer to the date ranges on page 1.) If additional space is needed, please type on a separate document. Periods of Enrollment Institution Award Year Transcript Submitted? (Yes/No) Credit or Hours Earned? (Yes/No) Example: ABC Technical School Yes No Page 3 of 7

4 No Transcripts and/or No Academic Credit/Hours Earned: If you indicated No to submitting transcripts or earning academic credit or hours in the Periods of Enrollment table, please explain why in the table below. If additional space is needed, please type on a separate document. No Transcripts and/or No Academic Credit/Hours Earned Example: ABC Technical School I broke my leg on August 13, 2011 and was on bed rest for three months, leaving me unable to attend school. Medical Records Page 4 of 7

5 No Transcripts and/or No Academic Credit/Hours Earned Page 5 of 7

6 No Transcripts and/or No Academic Credit/Hours Earned Note: The University may request additional information to support your circumstance(s) after the request form is received. CERTIFICATION STATEMENT I certify that the submitted information is true and correct to the best of my knowledge and belief. I have read each section and have provided the required supporting documentation. I acknowledge by signing below that my request may not be processed if I do not provide the required supporting documentation. Student Signature Date Fax this form, along with supporting documentation to Student Financial Services - Operations at (877) Page 6 of 7

7 Fax Coversheet Student Financial Services Operations Fax: (877) Student Name: Date: IRN: Number of Pages (including coversheet): Please indicate the supporting documentation you are including with the coversheet: *All statements must be signed and dated* Unusual Enrollment History review form (all pages must be fully completed) Official/unofficial transcripts, grade reports, etc. Third-party statements on official letterhead, signed and dated (not acceptable from family/friends) Official supporting documentation Other, please specify: Page 7 of 7