Need Based Financial Aid Appeal Form (2023-2024)

Simmons University
Student Financial Services

Financial Aid Packages are based on prior year income. If your family has experienced significant and/or unforeseen changes in your financial circumstances that affect your family’s ability to contribute to college costs you may request an appeal of your need based financial aid.

Enrollment decisions should always be made based on the current award package, as an appeal does not guarantee additional funding.

Student Name Student Name First Last
Simmons ID or DOB (MMDDYYYY)
Maximum of 8 digits allowed. Currently Entered: 0 digits.
Student Email
What is the reason for requesting an appeal?

What is the reason for requesting an appeal? Significant Loss of Parent, Student, or Spouse's Work Income in 2022 (for more than 10 weeks) Significant Loss of Parent, Student, or Spouse's Work Income in 2023 (for more than 10 weeks) Family's Unusually High, Uninsured Medical Expenses Loss or Reduction of Taxed/Untaxed Income
Significant Loss of Parent, Student, or Spouse's Work Income in 2022

In detail, please explain the circumstances surrounding the loss of work income including who lost income, date of income loss, cause (disability, death, forced retirement, termination, layoff) and any relevant details.
Significant Loss of Parent, Student, or Spouse's Work Income in 2023

In detail, please explain the circumstances surrounding the loss of work income including who lost income, date of income loss, cause (disability, death, forced retirement, termination, layoff) and any relevant details.
Family's Unusually High, Uninsured Medical or Dental Expenses

In detail, explain the circumstances contributing to the excessive uninsured medical and/or dental expenses, and the amount that was incurred by your family.
Loss or Reduction of Taxed/Untaxed Income and Benefits

In detail, explain the circumstances relating to the loss or reduction of taxed or untaxed income and benefits from 2022 (such as child support, unemployment compensation, etc) Include who received the income/benefit and why they will not be recurring in the future (2023 and beyond).
Special Circumstances
Required Documentation

Please submit each of the following documents via our Secure File Transfer System.
Signed copy of your 2022 IRS 1040 All 2022 W-2's
Signed copy of your 2022 IRS 1040 Final 2023 Pay Stub(s) and Documentation to support all resources entered above (if applicable) Documentation of unemployment compensation (if applicable)
Schedule A (From IRS form 1040) if filed with these expenses OR Uninsured medical or dental expense documentation that indicates the amount of the expense and shows that they were not covered by insurance.
Required Additional Information

Please provide the estimated TOTAL 2023 income from the below sources. INCLUDE INCOME BOTH EARNED TO DATE AND ESTIMATED TO YEAR END.
Parent 1 name
2023 total estimated Parent 1 wages
Parent 2 name
2023 total estimated Parent 2 wages
2023 total estimated student wages
2023 total estimated interest & dividend income
2023 total estimated unemployment compensation
2023 total estimated severance pay
2023 total estimated IRA, pension or annuity distribution
2023 total business income
Any other taxable income
2023 total estimated child support received
2023 contributions to retirement accounts
Any other untaxed income
Required Additional Information

Please complete the Sources of 2022 Untaxed Income Below
Payments to tax-deferred pension and savings plans
Deductible IRA and or SEP/SIMPLE
Child Support Received
Housing,food,and other living allowances paid to members of military, clergy, others. (do not include value of on-base housing or basic living allowance)
Veteran's non-educational benefits, such as Death Pension or Dependency & Indemnity Compensation (DIC)
Any other untaxed income/benefits
By submitting this form, you agree to the following:
I certify that,

I certify that, To the best of my knowledge, the information provided in this appeal is correct and complete. I understand that falsification of any of the informationin in my appeal could jeopardize my financial aid eligibility. I understand that completing this form does not guarantee that financial aid will be increased. I understand that if my financial aid is revised based on projected income, SFS may require verification of projected income and financial aid may be revised if projected income was inaccurate.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Type the letters you see in the image below.

Need Based Financial Aid Appeal Form (2023-2024)

Need Based Financial Aid Appeal Form (2023-2024)

Significant Loss of Parent, Student, or Spouse's Work Income in 2022

Significant Loss of Parent, Student, or Spouse's Work Income in 2023

Family's Unusually High, Uninsured Medical or Dental Expenses

Loss or Reduction of Taxed/Untaxed Income and Benefits

Required Documentation

Required Additional Information

Required Additional Information

By submitting this form, you agree to the following: