STUDENT EMERGENCY FUND REQUEST Instructions You Must: 1. Complete and sign all sections of the form. 2. Attach any supporting documentation explaining circumstances (i.e., medical bills, auto repair estimate, etc.). 3. Optional: Attach recommendation from an ACC Support Center Advocate, Advisor, or other Faculty or Staff member. 4. Submit Completed Form: Turn in to any campus Financial Aid Office, fax to 512-223-7963, or email to
[email protected]. Request form will be reviewed and you will be contacted if any additional information is needed.
Your Information Name:
ACC ID#:
Phone #(home/cell):
Semester in which the emergency occurred:
Amount Requested: $
On Page 2: In the area provided, briefly describe your unanticipated financial emergency or catastrophic event and how these funds will be used. Please describe how you will manage your future financial needs. (Attach additional page(s) if necessary.) Are you working with a Support Center Advocate? Note: Some applicants will be required to meet with a Support Center Advocate Yes
If Yes, please list advocate’s name:
No
If No, which campus do you prefer
How will you use funds? (Check all that apply) Living Expenses Dependent Care
Utility Expenses (City of Austin) Utility Expenses (Not City of Austin)
Medical Expenses Transportation
Hurricane Harvey Recovery
Other (if all other options do not apply) I affirm that all information on this form is complete, true, and correct and that I am in need of these funds in order to continue my education at Austin Community College. The information provided on this form may be used for research purposes, and we may be required to share information with college representatives or grant sponsors. Student’s Signature
Date
Someone may contact you to review your budget and to provide you with additional resources including financial literacy, planning or coaching. Please note that the phone number you provided above and/or your official ACCmail account may be used to contact you if additional information is needed.
Your Financial Information Marital status:_________________
Number of Dependents in Household: _________
Estimated Expenses (Per Month) Rent/Mortgage $ Food $ Transportation $ Utilities $ Child Care $ Phone/Cable/Internet $
Estimated Income (Per Month) Earnings of Student $ Earnings of Spouse $ Parent’s Contribution $ Savings $ Child Support Received $
Other Expenses (i.e., prescription costs): Expense:______________ $______________ Expense:______________ $______________
Other resources: (i.e., TANF, DARS, SSI…): Resource:______________ $____________ Resource:______________ $____________
Total Expenses Per Month
Total Income Per Month
$0
$0
STUDENT EMERGENCY FUND REQUEST
Page 2 Name:
ACC ID#:
Please indicate the extra pages you are attaching by checking the boxes: Additional "Brief Description" pages are attached
Additional "Recommendation" pages are attached
Additional supporting documentation attached (i.e., medical bills, auto repair estimate, utility bills, etc.).
Your Information: Brief Description Description of unforeseen circumstances or financial emergency and how you will manage your future financial needs. (Attach additional pages if necessary)
IMPORTANT! If your expenses exceed your income, please provide a brief explanation for how you are supporting yourself. (Attach additional pages if necessary)
Optional - Recommendation
Recommendation may be provided by an ACC Support Center Advocate/ Advisor/ Faculty/ Staff To strengthen your application, you are strongly encouraged to meet with an ACC representative who can provide a written recommendation for emergency assistance. **Please attach letter of recommendation or use the space below to provide a note regarding the student’s progress toward academic goals and/or financial need, if known.
___________________________________ ACC Representative’s Signature
Printed Name
______________________________ Date ______________________________ Position/Title
