Academic and Financial Aid Appeal Form

Complete this form to request to return to Herkimer County Community College following your dismissal. Due to your academic dismissal you are not currently eligible for federal financial aid. If you feel you have extenuating circumstances that led to your dismissal, this appeal will also be evaluated by the Financial Aid Office for potential reinstatement of federal aid.

*All fields required

First Name

Last Name

Student ID# if known (example below)

Email Address

Primary Phone (no spaces or special characters)

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Which term are you interested in returning?
Please indicate one of the following: winter mini, spring semester, summer mini, fall semester.

Major

I want to appeal for reinstatement of my federal financial aid eligibility

Yes

Course schedule I'm requesting

Full-time

Part-time

I request to study

Main Campus/In-Person

Internet Academy

Select the condition(s) that indicate why you are appealing:

Please thoroughly answer the following questions. This is the most important part of the appeal as it tells the reviewer what lead to your standing and what you will do to ensure a different result in your return semester. Recommendation: complete these questions in a separate document and copy and paste your proofread answer into the appropriate field.

1. The specific extenuating/extraordinary circumstances that led to your academic difficulties
during your most recent semester at Herkimer College.

2. How the circumstances have been resolved.

3. An outline of your plan to remedy the academic issues that led to your dismissal (include
any campus resources that you will use).

Please scan and email any supporting documents to advisementcenter@herkimer.edu.

I hereby certify that:
*The information I am providing is complete and accurate to the best of my knowledge.
*I have reviewed the Satisfactory Academic Progress (SAP) policy as outlined on the college web-site
www.herkimer.edu/standards-and-regulations/
*I understand that if my financial aid (grants and loans) appeal is denied, I am not eligible for federal
financial aid and I will have to find alternative financing to pay the required charges by the due date
of the bill.
*I understand financial aid decisions are independent from academic reinstatement decisions and all
decisions are final.
*I understand that I will be required to comply with an Academic Recovery plan that will be monitored
by various offices throughout my return semester.

Signature (your full name)