Excelsior Scholarship Appeal Form

Appeal form for continuing Excelsior scholarship recipients that experienced an ineligible determination based upon extenuating circumstances.

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Read why You may be Eligible for an Excelsior Scholarship

If you were recently notified that, since first enrolling in college, you (a) failed to complete an average of at least 30 combined credits per year applicable to your degree program, (b) failed to have sufficient credits accepted at SUNY Brockport, or (c) failed to be continuously enrolled, you may still be eligible for an Excelsior Scholarship.

Interruptions in Study.
By law, applicants who completed fewer credits than required and/or had a break in attendance due to (a) the death or illness of a family member, (b) documented medical leave, (c) active military service, (d) parental leave, or (e) a disability as defined by the Americans with Disabilities Act of 1990, as amended, may still be determined eligible for an Excelsior Scholarship award. If you meet one of these conditions, please complete sections I through IV below.

If you had a medical diagnosis and were unable to complete coursework, instructed to reduce your coursework, or withdraw for a term by your physician or health care provider, you must have your physician/health care provider complete section V.

Please note that all required information and documentation must be provided when submitting the Eligibility Determination Form. The eligibility determination made upon reviewing your documentation shall be based on the rules governing the Excelsior Scholarship and shall be the final determination.
I. PERSONAL STATEMENT (Required) – Please provide a brief personal statement explaining the circumstances resulting in your interruption in studies which prevented you from meeting the eligibility requirements. Please note that circumstances other than those indicated above do not meet criteria as defined by State Education Law to enable you to retain your award.
II. REASON FOR YOUR INTERRUPTION IN STUDIES (Required) – Check one and provide the required documentation with your completed form.

II. REASON FOR YOUR INTERRUPTION IN STUDIES (Required) – Check one and provide the required documentation with your completed form. ADA Disability (Section III and IV to be completed by your health care provider) Medical (Non-ADA) (Section III and IV to be completed by your health care provider) Mental Health (Section III and IV to be completed by your health care provider) Care for Newborn (Must be within one year of birth, please provide copy of birth certificate)) Adoption/Placement of Foster Child (must be within one year of placement, please provide Letter of Placement) Medical - Care of Family Member (Letter from health care provider of family member containing dates, diagnosis and relationship) Bereavement - Death of Immediate Family Member (Death Certificate and relationship) Military (Department of Defense Orders) Divorce - Self or Parents (Divorce Decree) Unemployment - Parent or Spouse (Unemployment Eligibility Letter or 1099-G Form) Volunteer Program (i.e. Peace Corps and AmeriCorps, Certification of Service) Other (Explanation of Appeal
III. MEDICAL INFORMATION

If you have indicated that you have/had a medical diagnosis that required that you to leave school or attend less than full time, your licensed physician/health care provider must complete this section on their letterhead, which you will upload below.

The above patient is an applicant for a NYS scholarship administered by the Higher Education Services Corporation (HESC). In order to make an eligibility determination, please provide the following information. Use additional sheets, on physician/healthcare provider’s letterhead, if necessary. Please complete section V in its entirety. Incomplete medical information may result in the denial of the student’s application.

1. Was it due to your medical recommendation that the student stopped and/or reduced their college coursework based on his/her medical condition?

2. Please indicate the extent to which the student’s medical condition impacted his/her college attendance, whether it resulted in a reduction in credit load or break in enrollment.

3. If applicable, did the student’s medical condition necessitate a change in his/her program of study?

4. Did the student change the college he/she attended due to the medical condition?

5. Briefly explain how/why this student’s medical condition impacted his/her college attendance and if this student has any restrictions upon returning to his/her college studies.
IV. File Upload - Please upload any documentation pertinent to your Excelsior eligibility determination below.
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
V. STUDENT AFFIRMATION
By my signature below, I affirm, under the penalty of perjury, that the information I provided, and any supporting documentation submitted, are true and complete and will be accepted for all purposes as the equivalent of a sworn affidavit.

Type your full name as a legal representation of your signature into the box below.

Excelsior Scholarship Appeal Form

Read why You may be Eligible for an Excelsior Scholarship

III. MEDICAL INFORMATION

V. STUDENT AFFIRMATION