University of California, Berkeley
Financial Aid Parent Contribution Appeal
Deadlines: This appeal must be submitted by February 1, 2010. If you are enrolled for
2009-2010
the fall semester only, this appeal must be submitted by October 1, 2009.
• Please use black ink (no fine point) and make sure all documentation is legible.
• Include the student's name and social security number on each page of documentation.
• All documentation must be on 8 1/2 x 11 inch paper.
Student name:______________________________________________________________________________
Soc. Sec. #: __________________________________ Student I.D.# __________________________________
Student E-mail:_______________________________ Parent E-mail: ________________________________
Student Phone: _______________________________ Parent Phone: ________________________________
Instructions If there has been a change in family financial circumstances from 2008 to the present, which is beyond
your (the parents') control and you wish to appeal the parent contribution, you must provide:
• A letter of explanation describing, in detail, the circumstances of your appeal.
• Copies of all appropriate documentation specifically pertaining to your circumstance.
• A complete copy of your (the parents') 2008 Federal Income Tax Return with all W2s and schedules (if not
already submitted).
• This form with page 2 completed and signed by the parent.
• Additional information that applies to your specific situation.
The following are circumstances that may be considered:
1. INCOME REDUCTION
a. Provide copy of employment termination letter, including verification of severance pay or retirement benefits or
explain why you do not have one of the above documents.
b. Provide copy of unemployment benefits (if not provided, we will assume $450 per week for one year).
c. Provide copy of disability benefits eligibility.
d. Provide copy of termination notice of other income (e.g., Social Security).
e. Provide copy of year-to-date earnings (copy of last paycheck stub).
f. If you are self employed, provide copies of your prior year and current year profit and loss statements.
g. Provide copy of divorce/separation agreement.
2. DEATH OF A PARENT
a. Provide copy of death certificate,
b. Provide documentation of death benefits and insurance payments.
3. UNUSUAL AND NECESSARY EXPENSES
a. Medical emergencies: provide statement from insurance provider stipulating amount of medical expenses not covered
by insurance.
b. Tax liens: provide statement from Internal Revenue Service and /or State Franchise Tax Board indicating monthly
payment amount on back taxes owed prior to 2008.
Important: Any changes to financial aid awards will be contingent on the type of funds available, eligibility
policies and regulations.
Office Use Only
Counselor/Date:
Comments:
Forms; ParentContributionAppeal53-0910; ldp-3/12/09
*%5310*
PARENTS' EXPECTED INCOME
Date of Income Change: _________________ (month/day/year). Report income that you, the parent(s),
received and/or expect to receive for the 12-month period following the date that your income changed.
Monthly One-Time End Date
Income Source Amount Payment (Provide documentation)
TAXABLE INCOME
Income earned from work by father: __________ __________ ________________
Income earned from work by mother: __________ __________ ________________
Severance pay: __________ __________ ________________
Retirement benefits: __________ __________ ________________
Social Security Benefits (SSB): __________ __________ ________________
Unemployment benefits: __________ __________ ________________
Business/farm income: __________ __________ ________________
Rental property: __________ __________ ________________
Alimony: __________ __________ ________________
Other taxable Income (specify):
__________________________________ __________ __________ ________________
NON TAXABLE INCOME
TANF/AFDC: __________ __________ ________________
Social Security Benefits (SSB): __________ __________ ________________
Workers Compensation/Disability: __________ __________ ________________
Child Support: __________ __________ ________________
Other untaxed income (specify):
__________________________________ __________ __________ ________________
OTHER NON TAXABLE INCOME
(Not reported on FAFSA)
Supplemental Security Income (SSI): __________ __________ ________________
Money received or paid on your behalf : __________ __________ ________________
I certify that all the information on this form is true and complete and I will report any changes in writing to the Financial Aid
and Scholarships Office.
Parent Signature_________________________________________ Date _______________________
Reminders:
• Did you provide a letter of explanation regarding your appeal?
• Did you provide all appropriate documentation in support of your appeal?
• Did you provide a copy of your 2008 Federal Income Tax Return?
• Did you sign and date this form?
To expedite the processing of this form, you may fax it to our Financial Aid Forms Fax: 510-643-2015
University of California, Berkeley, Financial Aid and Scholarships Office, 211 Sproul Hall, Berkeley, CA 94720-1960
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