Fillable Cost Of Attendance Appeal Independent Student

COST OF ATTENDANCE APPEAL

INDEPENDENT STUDENT

2015-2016 ACADEMIC YEAR

Student Information

Name __________________________________________

Student ID Number __________________________

Cost of Attendance Adjustment Request

Please select the term for which you are appealing:

Fall

Spring

Summer

Please select the category for which you are appealing:

 Category 1. Other direct educational expenses incurred for the 2016 academic year.

Total itemized expenses: $_________________

Please attach the required documentation:

Necessary supplies, equipment, or travel—requires Department Memo with documentation.

Required Textbooks—receipts, print-out of required textbooks for course, etc.

Tuition or other program charges on Bursar statement—no additional documentation required

 Category 2. Purchase of personal computer for the 2016 academic year.

Purchase price of computer: $________________

Please attach Webpage print-out of expense or Receipt of purchase for the 2015-2016 academic year.

Note: Department Memo is required for computer purchases over $2000.

 Category 3. Uninsured necessary medical expenses incurred for the 2016 academic year.

Expenses for other family members are not applicable.

Current monthly medical premiums:

$________________________

Uninsured medical/dental expenses incurred

$________________________

Anticipated* uninsured medical/dental expense

$________________________

Please attach copy of documentation for necessary medical or dental expenses.

*Anticipated expenses must include signed statement from medical provider.

 Category 4. Childcare expenses incurred in order to attend classes for the 2016 academic year.

Monthly childcare expenses: $________________________

Does spouse attend college or work outside the home?

Yes

Do they attend IUB?

Yes

If yes, please provide spouse name and ID#:______________________________________________________

Please attach receipt or other documentation from daycare/childcare provider.

Consent and Signature

Signature certifies that you have read the statement below. Form must be signed and dated by student. Not signing will delay or

prevent completion of form. Please allow 10-15 business days for processing. Please submit no later than 30 days before the end of the

enrollment period.

I give permission to the Office of Student Financial Assistance to verify any information that I provide on this form. I understand that

this verification may include a request for my tax documents. I certify that all of the information provided on this form is correct to the

best of my knowledge. I understand that if I purposely give false or misleading information on this form I am liable for cancellation or

repayment of all or part of my financial aid. In addition, I understand that completing this form does not guarantee an increase or

adjustment in financial aid.

Don't type signature. Please print form and sign.

Student Signature______________________________________________

Date______________________________________

408 N. Union St. Bloomington, IN 47405 

phone (812) 855-6500 fax (812) 855-7615blfinaid@indiana.edu 

Cost Of Attendance Appeal Independent Student - 2015-16

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