Fillable Unusual Enrollment History printable pdf download

OFFICE USE ONLY

Document Code: _CF0359/CF0360

Date Received:

Form Received by:

STUDENT FINANCIAL AID

Unusual Enrollment History

ACADEMIC YEAR 2015-2016

Student Name:

NSHE ID:

Your 2015-2016 Free Application for Federal Student Aid (FAFSA) has been flagged by the U.S. Department of Education for “Unusual

Enrollment History” (UEH) review because you received Federal Pell Grant funds at multiple institutions during the award periods of

2011-2012, 2012-2013, 2013-2014, and 2014-2015. This flag requires CSN to review your enrollment history and determine whether or

not you earned academic credit while receiving federal student aid. CSN must verify the names of the institutions you have attended,

the dates of your attendance, as well as the aid you received during this review period, via the National Student Loan Data System

(NSLDS). You can view your entire Grant and Student Loan history at:

Please attach documents as follow:

□

Official Academic Transcripts for all schools attended during the award years:

2011-2012, 2012-2013, 2013-2014 and 2014-2015 exclude CSN Transcripts.

□

Explanation for any non-completion of enrollment periods during the award years:

2011-2012, 2012-2013, 2013-2014 and 2014-2015, include documentation (i.e., medical bills, hospitalization

records, accident reports, etc.) that supports your reason for withdrawal(s).

□

Academic Plan – Please meet with your advisor and develop an Academic Plan based on your declared

major. PLEASE NOTE: Academic Plan only becomes valid, should this UEH petition be approved.

Complete the chart below. List all institutions (including CSN) you attended during the award periods of 2011-2012, 2012-2013,

2013-2014 and 2014-2015. If necessary, attach a separate sheet. Failure to report all institutions attended and/or provide

official academic transcript(s) will result in delay of processing this review and result in denial of aid.

Types of Aid Received (e.g. Pell

Name of College or University

Dates of Attendance

Grant, Student Loans, etc.)

Special Notes: I affirm that I have read and understand this form in its entirety and that the information I supplied is true and

complete. I am aware that failure to provide above documents will result in an automatic denial of future federal student aid at

CSN. I also understand that completing this form does not guarantee that I will be awarded financial aid at CSN. Should I choose

to continue enrollment, I understand that I am responsible for tuition payment. The UEH evaluation may impact my financial aid

eligibility, but this requirement does not impact my admission to CSN.

Date

Student Signature

Unusual Enrollment History