Financial Hardship form - OSU Residential Life

FINANCIAL HARDSHIP EXEMPTION APPLICATION
Although the University feels that students will have their best opportunities for a well-rounded educational experience living
in a supervised residence hall designed for student living, there are some circumstances under which a student may be
approved to live off campus. In the event a student presents sufficient evidence of an extreme financial hardship which
precludes his/her enrollment at OSU; the student may receive approval to live off campus. However, costs of on campus
room and board will usually be found comparable to those off campus after all necessary living expenses have been
accounted for. Students requesting permission to live off campus due to a financial hardship must provide Housing &
Residential Life with the following documents:
This form, notarized, and with all sections completed.
The Application for Freshmen Residency Requirement.
Free Application for Federal Student Aid (FAFSA) for term in which exemption is being requested (I-20 for
international students).
I hereby give permission for Oklahoma State University’s Office of Scholarships & Financial Aid to provide my FAFSA
information to Housing & Residential Life for use in determining financial need.
_________________________ ________________________ _________________________
(Student’s Signature) (Date) (Student ID Number - CWID)
_________________________
(Student’s Name, Printed)
Address where student proposes to reside, if approved (Please note, students should not obligate themselves to any off
campus arrangements prior to receiving written notification of this office’s decision.):
____________________________________________________________________________________________________
(Names of Co-Resident)
(Age/classification/relationship to student)
____________________________________________________________________________________________________
(Names of Co-Resident)
(Age/classification/relationship to student)
___________________________________________________________________________________________________
(Apartment Complex or address if living in a house)
(Telephone Number)
I verify that the information provided here is true and correct, and I understand that false or misleading information provided
by me shall be grounds for taking disciplinary action against me in accordance with the Student Code of Conduct. I also
understand that all information provided is subject to verification and that additional information may be required by
Housing & Residential Life.
Student Name (Please Print)
Student ID Number (CWID)
Student Signature Telephone Number Date
Please return to: OSU Housing & Residential Life, 100 Iba Hall, Stillwater, OK 74078 or Fax it to 405-744-6775

FAMILY’S HOUSEHOLD
EXPENSES
STUDENT’S PROJECTED
OFF-CAMPUS EXPENSES
COMPARATIVE
ON-CAMPUS EXPENSES*
Rent/Mortgage: $_________ Rent: $_________ Room:
(On-Campus
$ 362.00
($648 avg.)
Apartment Rates)
Utilities: $_________ Utilities: $_________ Utilities: included
Car Payments: $_________ Cable Serice: $_________ Cable Service: included
Insurance (car): $_________ Internet Service: $_________ Internet Service included
Insurance (health): $_________ Transportation to
Transportation included
Campus:
$_________ (Close proximity to
classes/bus routes)
Groceries: $_________ Food: $_________ Meals:
$ 344.44
Transportation: $_________ Total: $_________ Total:
$ 706.44
Other: __________ $_________
Other: __________ $_________ All associated expenses must be
listed, even if supplied by parents
(i.e. cell phone bills, gas cards, etc).
*Comparative
monthly expenses
based on 2009/2010
Total:
$_________
housing rates for
double occupancy in
a traditional hall
with a Platinum
mealplan.
If your family’s income has changed dramatically compared to what is shown on last year’s income tax return or FAFSA,
please explain here:
If my student has to reside on campus, our family finances will be negatively affected in the following way:
I, __________________________, do hereby swear or affirm that I am the parent or legal guardian of the student,
__________________________, and that the preceding statements are true and correct.
________________________ _______________________ ________________________
(Parent’s Signature) (Print Parent’s Name) (Date)
State of Oklahoma
County of _______________
Before me, (insert the name and character of the officer), on this day personally appeared
____________________, known to me (or proved to me on the oath of ______________ or through (description of identity
card or other document)) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that
he executed the same for the purposes and consideration therein expressed.
Given under my hand and seal of office this __________ day of __________, (year).
______________________
Notary Public's Signature
Please return to: OSU Housing & Residential Life, 100 Iba Hall, Stillwater, OK 74078 or Fax it to 405-744-6775