Undergraduate Emergency Request 2023-24

If you encounter financial circumstances that are above the standard cost of attendance, the university can sometimes help. Please use this form to describe your circumstances and attach supporting information and/or documentation. Please note that to provide you funding, we must have documentation of the expense. Be sure to upload a copy of your bill and proof of payment with the button on the bottom of this form. If you have questions, please contact the office or provide information in the description below. Because our ability to address your emergency funding request requires you to be a currently enrolled student, you should submit all requests in the term the expense occurs.

Please feel free to speak with a financial aid counselor if you have questions or need help completing the form. If you have specific concerns, please contact Adom Harris (adom.harris@northwestern.edu).

Please indicate your program type:

Please indicate your program type: Undergraduate Graduate/Professional
Please contact your Financial Aid Office. This form is for requests from Evanston undergraduate students. Please contact your financial aid office to explore your options. A list of office contacts can be found at https://www.northwestern.edu/sfs/about/contact/offices.html.
Your Name Your Name First Last
Your Student ID Number
Must be 7 digits. Currently Entered: 0 digits.
Your Email Address
Your Phone Number Your Phone Number - ### - ### ####
The expense that I am reporting was incurred during a time period I was actually enrolled. I understand I am not eligible to apply for emergency aid for an expense incurred while not enrolled (For example, reimbursement is not available for the summer term if I was not enrolled for summer.)

The expense that I am reporting was incurred during a time period I was actually enrolled. I understand I am not eligible to apply for emergency aid for an expense incurred while not enrolled (For example, reimbursement is not available for the summer term if I was not enrolled for summer.) I understand
I understand that the expenses must be submitted within the academic term (fall, winter, spring) that the expense actually occurred.

I understand that the expenses must be submitted within the academic term (fall, winter, spring) that the expense actually occurred. I understand
If you were referred to our office by someone, please indicate their role:

If you were referred to our office by someone, please indicate their role: University Faculty University Staff Other (please expand below)
Name of person who referred you and any other additional pertinent information regarding the referral:
I am requesting emergency assistance for one of the following (in almost all cases we will need a copy of the paid bill from your provider, please upload a copy with the link on the bottom of this form):

I am requesting emergency assistance for one of the following (in almost all cases we will need a copy of the paid bill from your provider, please upload a copy with the link on the bottom of this form): Medical Expenses (emergency room, ambulance, office visit...etc.) Vision Expenses Dental Expenses Atypical or Nonstandard Housing Expenses Atypical or Nonstandard Food Expenses Expenses Not Categorized Above
I am requesting this amount in Emergency Aid. If you are unsure of the amount, please wait and complete this form when the expense is known. If you have questions in the meantime, please contact the office. $ Dollars . Cents
To provide funding, we must know an amount. If this is a large expense and you need advance funding, you will later need to provide receipts. If advance funding exceeds your eventual bill, you will be required to reimburse the university. If you need advance funding for a large expense, please describe below.
Please note that your expense may need to be reviewed by the university's Patient Advocacy Coordinator to determine if costs can be reduced with the care provider. Upon completion of that review, the expense will then be reviewed by the financial aid office.

Please note that your expense may need to be reviewed by the university's Patient Advocacy Coordinator to determine if costs can be reduced with the care provider. Upon completion of that review, the expense will then be reviewed by the financial aid office. I understand
Please describe the nature of your request and upload documentation of the expense below.
Please upload documentation of your expense(s). In the case of medical expenses, please provide documentation from your medical provider. Help for medical expenses cannot be provided without documentation.

Attach Files

HEIC files are not compatible with this form.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. By signing this, I confirm that I am the individual completing this form and all the above information is accurate and true. Clear

Full Name

I understand this is a legal representation of my signature. By signing this, I confirm that I am the individual completing this form and all the above information is accurate and true.

Undergraduate Emergency Request 2023-24

Undergraduate Emergency Request 2023-24

Please contact your Financial Aid Office. This form is for requests from Evanston undergraduate students. Please contact your financial aid office to explore your options. A list of office contacts can be found at https://www.northwestern.edu/sfs/about/contact/offices.html.