HEERF – DEMONSTRATED HARDSHIP FORM

This form will not be considered unless all the required documentation is attached.

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Student Name*

First Last

Cell Phone*

Email*

Current Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The Coronavirus Response and Relief Supplemental Appropriations Act, 2021 (CRRSAA) provides emergency assistance for students who are in need of financial support for expenses related to the disruption of campus operations due to the coronavirus pandemic. Under CRRSAA, McDougle Technical Institute (the “Institute”) has received grant funding from the U.S. Department of Education for the purpose of making emergency financial aid grants to its students

As part of the Institute’s student grant allocation formula, students who have recently experienced demonstrated hardship may be allocated a share of grant funds. Any student seeking consideration for an emergency financial aid grant award due to Demonstrated Hardship should submit the Demonstrated Hardship form and supporting documentation as soon as possible. The Institute will make emergency need-based grants to eligible students until the grant funding received from the U.S. Department of Education is depleted. Students who submit the Demonstrated Hardship form and supporting documentation after the grant funding is depleted will not be considered for any grant allocation due to Demonstrated Hardship.

Please indicate the special circumstances of demonstrated hardship that you wish for the Institute to consider in its allocation of emergency financial aid grants to students (choose all that apply):

Loss of Employment

Reduction of Income

Divorce/Separation

Unusual Medical/Dental Expenses

Death of Parent or Spouse

Please upload supporting documentation based on your special circumstance(s):

Reduction of Income*

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Max. file size: 100 MB.

Reduction in Wages/Hours: Current employer has reduced wages and/or hours for at least 12 consecutive weeks in 2020 or 2021 for you, your spouse, or your parent (if dependent). Documentation Needed: Employer documentation verifying change in employment status (e.g. furlough) Copy of paycheck stub(s) received before reduction and copy of most recent paycheck stub(s) since reduction in 2020 or 2021 Reduction in Income/Benefits: You, your spouse, or your parent(s), if dependent, lost income or benefits outside of employment (i.e. child support, unemployment, etc.). Documentation Needed: Third-party official documentation reporting date income or benefit was terminated/exhausted.

Divorce/Separation*

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Max. file size: 100 MB.

For separation: Signed statement indicating date of separation and two official documents (e.g., copy of lease, utility bill, driver’s license, etc.) verifying the physical address of the absent spouse/parent (no P.O. boxes) For divorce: A divorce decree

Unusual Medical/Dental Expenses*

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Max. file size: 100 MB.

Medical and/or dental expenses for 2020 or 2021 that were paid out-of-pocket (i.e. not what insurance covered) for you, your spouse (if applicable) and/or your parent(s)/sibling(s), if dependent. Documentation Needed: Copies of canceled checks for out-of-pocket payments and/or receipts of payments A copy of your FSA or HSA account showing payments and/or a copy of your medical account listing payments and dates.

Death of Parent or Spouse*

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Max. file size: 100 MB.

Copy of the death certificate or a published newspaper obituary with date of death.

Loss of Employment*

Drop files here or

Max. file size: 100 MB.

Official documentation verifying date of job loss (e.g. severance letter, unemployment decision, etc.) Final paycheck stub(s) received Unemployment history summary reporting benefits received to date and balance remaining in 2021 If employed after job loss, please include most recent paycheck stubs of any and all employment

Circumstances that are NOT considered as extenuating include, but are not limited to: Standard living expenses (e.g., utilities, credit card payments, etc.) Mortgage payments Car payments Credit card or other personal debts Vacation expenses All other discretionary expenses

Any request for special consideration of demonstrated hardship must include a detailed written explanation from the student and supporting documentation.

Any Demonstrated Hardship Forms submitted without either a detailed written description or supporting documentation will not be considered.

Are you seeking consideration for an additional emergency financial aid grant due to COVID related hardships?

If you answered YES, please provide a detailed description and supporting documentation of the COVID related hardship and why you should be considered for an additional emergency financial aid grant award.

Written Explination*

Please provide supporting documentation based on your special circumstances:

I certify the following:*

All information provided in this Attestation Statement is true and correct to the best of my knowledge.

I have experienced additional expenses due to the disruption caused by coronavirus.

I understand that any money awarded from this grant is to be used for any component of my cost of attendance or for emergency costs that arise due to coronavirus, such as tuition, food, housing, health care (including mental health care), or childcare.

I understand that I have the option, but that I am not required, to apply some or all of the Grant Award Amount toward my outstanding balance due to the Institute. Whether I choose to apply some or all of my Grant Award Amount toward my outstanding balance due to the Institute will not change my Grant Award Amount.

Please indicate your choice for the disbursement of your Grant Award Amount (choose one):*

I give my consent for the Institute to use my Grant Award Amount as payment toward my outstanding balance with the Institute. If the Grant Award Amount is greater than my outstanding balance, then the Institute will give me a check for the difference. If the Grant Award Amount is less than my outstanding balance, then I shall be responsible for any remaining balance due. I understand that my Grant Award Amount is not conditioned upon my consenting to the use of my Grant Award Amount as payment toward my outstanding balance due to the Institute.

Student Signature*

Date

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