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Medical Certificate Confirming a serious Episodic Disorder

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Form number: 1016

This form is to be used for applications relating to the September 1, 2022 – August 31, 2023 award year.

You need to use this form if your are required to temporarily move from full-time part to part-time status due to a serious episodic and permanent mental or physical health disorder.

This form will not be considered valid unless it has been filled out by your doctor.

Download the form

Digital transmission

Fill out your form, scan it and upload it to Your Student Financial Assistance File.

Other way to submit your document


Save the form to your computer to fill it out.  Once filled out, you must mail it to the address shown on the form itself.