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.
  • 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 NameStudent Last NameStudent Grade 
  • 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 NameP/G Last NameP/G Daytime Phone NumberP/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.
  • Part B.

  • Can you provide documentation of your change in circumstance(s)?
    Click the link below for a list of acceptable documentation for special circumstances.
  • 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.
  • 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.