2023-2024 Form 57 Unusual Enrollment History Appeal Form

2023-2024 Form 57 Unusual Enrollment History Appeal Form
Campus Location*
The Department of Education has selected your file for review due to a pattern of unusual enrollment history at colleges you have attended. You must submit this form and any required documentation to determine your financial aid eligibility.
Student Information
Name*

First NameLast Name
Student ID
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Schools Attended
List all schools that you received Pell Grant and/or Federal Direct Loans during the 2019-2020, 2020-2021, 2021-2022, 2022-2023 academic years. You must provide academic transcripts from all schools you list in the boxes below unless you have already provided these transcript(s) to Heritage University.

	Name of School	Dates of Attendance (M/Y to M/Y)	Did you Earn Credits/Clock Hours?	Did you Provide a Transcript to Heritage University?
School 1
School 2
School 3
School 4
School 5

Reasons for Financial Aid Appeal Request
If you answered "No" to the Credit/Clock Hours Earned question for any of the schools you listed above, you must provide an explanation of the special circumstance(s) that caused your failure to earn academic credit/clock hour.
If you answered "No" to the Credit/Clock Hours Earned question for any of the schools you listed above, you must provide an explanation of the special circumstance(s) that caused your failure to earn academic credit/clock hour. (Academic credit is considered to have been earned if the academic records show that the student completed any credit hours or clock hours.)
Supporting Documentation Upload
You must provide proof of your circumstance(s) such as: a statement from a doctor including a release to return to school, an accident report, military obligations, or an obituary. The circumstances must be reasons beyond your control, such as illness, accidental injury or death of an immediate family member.

****Failure to provide adequate documentation will result in your appeal being denied. ****
Upload your supporting documentation below:

Cancelof
Student Signature
My signature below verifies that I have read the procedures above and that all statements and documents attached are true and accurate.*

Clear
Have Questions About Your Financial Aid?

Financial Aid Office Contact Information

Address: ATTN: Financial Aid Office 3240 Fort Rd., Toppenish, WA 98948 | Phone: (509) 865-8502 | Email: financial_aid@heritage.edu
Should be Empty:

2023-2024 Form 57 Unusual Enrollment History Appeal Form

Student Information

Schools Attended

Reasons for Financial Aid Appeal Request

Supporting Documentation Upload

Student Signature