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Special Circumstance Financial Assistance Form
Special Circumstance Financial Assistance Form
This form should be completed when a family can document a significant change in financial circumstances, or if you believe there are special circumstances that warrant consideration of emergency financial assistance. You will be notified regarding the outcome of your appeal after your information is reviewed by the SMSA Business Office.
The completion of this form does not guarantee an adjustment or financial assistance.
Household Student Information
*
In order to add more than one student name, please click the plus sign to the right of "Student Grade" to add an additional line.
Student First Name
Student Last Name
Student Grade
Parent/Guardian Information
*
In order to add an additional parent/guardian, please click the plus sign to the right of "P/G Email Address" to add an additional line.
P/G First Name
P/G Last Name
P/G Daytime Phone Number
P/G Email Address
Part A. Submit the Following:
A written description explaining what caused the change(s) in your family's circumstances or the request for assistance.
*
A written description explaining what caused the change(s) in your family's circumstances or the request for assistance.
Part B.
Check ALL that apply to you
*
Loss of employment or change of employment status for student or parent/guardian
One-time payment reflected on 2018 taxes that created an unusual increase in income
Divorce or separation
Death of a student's parent/guardian
Loss of untaxed income (child support, pension, etc.)
Unusually high medical/dental expenses not covered by insurance or pre-tax medical savings/spending account
Private, non-SMSA, elementary, secondary or college school tuition for sibling(s)
Education Loan Payments made by parent/guardian for themselves
Incorrect financial information provided in initial application
Other circumstance(s) not listed above:
Documentation
*
Can you provide documentation of your change in circumstance(s)?
Click the link below for a list of acceptable documentation for special circumstances.
www.smsacademy.org/documentation
Yes! I can, upon request, provide documentation.
No, I cannot.
Part C.
We are working to match families with charitable partner organizations to provide assistance with food, rent, or other necessary expenses, in addition to financial assistance. Please check below indicating your interest in being considered for these funding opportunities as resources are identified.
Outside/Non-SMSA Financial Assistance
*
I/we would like to be considered for outside/non-SMSA financial assistance funding and allow SMSA to discuss my/our current circumstance
I/we do not wish to be considered for outside/non-SMSA financial assistance
Emergency Funding from Charitable Organizations
*
I/we would like to be matched for emergency funding opportunities such as assistance for food, rent, or other necessary expenses and I/we allow SMSA to share my/our contact information
I/we do not wish to be matched for emergency funding opportunities from other charitable organizations
Part D.
Carefully read the following before signing this form:
I/we understand that submission/review of this form does not guarantee a change in the student's financial aid eligibility, net tuition costs or financial assistance. I/we affirm that the information provided in my/our appeal and the documentation is accurate and complete to the best of my/our knowledge. I/we understand that if any of the information used in this appeal changes, I/we must contact the SMSA Business Office immediately in writing with the corrected information. I/we understand that false statements or misrepresentation may be cause for denial, reduction, withdrawal, or repayment of financial assistance.
Signature
*
I/we accept and agree