2022-2023 Professional Judgment Appeal

Indicates required field

Student Name

Student ID#

Parent(s) Name

Bluefield State recognizes that families experience special circumstances which merit recalculation of their financial aid
eligibility based on 2021 information, rather than 2020 income information. Please be advised that all professional
judgment appeal decisions are final.

Please check the box beside the circumstances that apply to your situation and submit the necessary paperwork.

Please check the box beside the circumstances that apply to your situation and submit the necessary paperwork.
Separation from employment due to layoff, termination, or disability Letter from employer on company letterhead including last date of employment Unemployment benefits determination document Signed copy of 2020 Tax Return, W-2's and Schedules 1,2, and 3 Signed copy of 2021 Tax Return, W-2's and Schedules 1, 2 and 3 Documentation of year-to-date income (last pay stub, severance pay, SSI benefits, etc.) Excessive non-reimbursed medical and/or dental expenses Documentation of non-reimbursed medical and/or dental expenses Canceled checks verifying payments made in 2021 and 2022. Copy of Schedule A from 2021 Federal Income Tax Return. Loss or reduction of untaxed income source (disability benefits, welfare benefits, child support, etc.) Copy of notification of benefits reduction/termination, including the effective date Documentation of 2021 or 2022 expected benefits Documentation of 2021 or 2022 year-to-date income (taxable and non-taxable) Separation or Divorce which occurred after completing FAFSA Copy of court order, final divorce decree or legal separation agreement Signed copy of 2020 and 2021 Tax Return, W-2's and Schedules 1,2,and3. Documentation of 2020 year-to-date income or 2021 Death of a parent (or spouse) which occurred after completing FAFSA Copy of death certificate Documentation of 2020 or 2021 year-to-date income (taxable and non-taxable) Other unusual circumstances Supporting documentation as requested by the Office of Financial Aid

Separation from employment due to layoff, termination, or disability

Letter from employer on company letterhead including last date of employment
Unemployment benefits determination document
Signed copy of 2020 Tax Return, W-2's and Schedules 1,2, and 3
Signed copy of 2021 Tax Return, W-2's and Schedules 1, 2 and 3
Documentation of year-to-date income (last pay stub, severance pay, SSI benefits, etc.)

Excessive non-reimbursed medical and/or dental expenses

Documentation of non-reimbursed medical and/or dental expenses
Canceled checks verifying payments made in 2021 and 2022.
Copy of Schedule A from 2021 Federal Income Tax Return.

Loss or reduction of untaxed income source (disability benefits, welfare benefits, child support, etc.)

Copy of notification of benefits reduction/termination, including the effective date
Documentation of 2021 or 2022 expected benefits
Documentation of 2021 or 2022 year-to-date income (taxable and non-taxable)

Separation or Divorce which occurred after completing FAFSA

Copy of court order, final divorce decree or legal separation agreement
Signed copy of 2020 and 2021 Tax Return, W-2's and Schedules 1,2,and3.
Documentation of 2020 year-to-date income or 2021

Death of a parent (or spouse) which occurred after completing FAFSA

Copy of death certificate
Documentation of 2020 or 2021 year-to-date income (taxable and non-taxable)

Other unusual circumstances

Supporting documentation as requested by the Office of Financial Aid

HOUSEHOLD SIZE (Number of people supported by household income)

NUMBER IN COLLEGE

Statement of Projected 2022 Income

This section asks about income and benefits that you and your family expect to receive between January 1, 2022 and now.

Taxable Income

Father’s earnings $

Mother’s earnings $

Student’s earnings $

Spouse’s earnings $

Untaxed Income

Unemployment Compensation Received $

Child Support Received $

Public Assistance $

Other Untaxed Income (workman’s compensation, Veteran’s benefits, cash support, etc.) $

By signing this document I/we certify that the information provided is complete and accurate to the best of my/our knowledge. I/we agree to provide more detailed documentation if required.

Student’s Signature

Sign above

Date

Spouse’s Signature

Sign above

Date

Parent’s Signature (if dependent student)

Sign above

Date

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