Page 1 TOPS Form 0004R Revised 09/21/2023
REQUEST FOR EXCEPTION FORM
TO THE INITIAL, FULL-TIME or CONTINUOUS, ENROLLMENT and/or 24 HOUR REQUIREMENT
Please follow the instructions on pages 2, 3 and 4. Email the completed form, your personal letter, and required
supporting documentation to TOPS.exceptions@la.gov.
IT WILL TAKE A MINIMUM OF 4 TO 6 WEEKS TO PROCESS THIS REQUEST - IF IT IS COMPLETE
A. MY STUDENT INFORMATION: (Print or Type)
Full Name:
DOB:
LOSFA ID:
Permanent Address (Street or P.O. Box) (Check If New ):
Current or Last College/University Attended:
City:
State:
Zip:
Current or Last Semester/Quarter/Term Attended:
E-mail Address:
College or University You Will Attend, if Reinstated:
Cell Phone: (_________) _________ - _____________ (Check If New )
Alternate Phone: (_________) _________ - ______________ (Check If New )
Semester/Quarter/Term You Plan on Returning to College:
B. MY PROGRAM:
Name of Scholarship/Grant/Program: _____________________________________________________________________________
C. MY QUALIFYING EXCEPTION TYPE: [Check the applicable type(s).]
1 - Parental (Pregnancy/Maternity/Paternity) Leave
8 - Death of Immediate Family Member
2 - Physical Rehabilitation Program
9A - Military Service - Student
3 - Substance Abuse Rehabilitation Program
9B - Military Service - Spouse
4A - Temporary Disability – Self
10 - Transfer to a Selective Enrollment Program
4B - Care of Immediate Family Member with Temporary Disability
11 - Unavailability of Courses
4C - Temporary Disability – Mental Health
12 - Natural Disaster
5 - Permanent Disability
13 - Exceptional Circumstances
6 - Exceptional Educational Opportunity
14A - COVID-19 - Fall 2020 – Summer 2022
7
-
Religious Commitment
14B
-
COVID-19 -Fall 2023 – Summer 2024
D. I NEED AN EXCEPTION FOR THE
FOLLOWING Semester(s)/Quarter(s)/Term(s):
_____________________________________________________________
E. MY SIGNATURE (Student’s): DATE:
OFFICIAL USE ONLY. (DO NOT MAKE ENTRIES BELOW.)
Date Request Received: __________________________________
H. S. Graduation Date: __________________________________
Last Semester/Quarter/Term Paid: _________________________
Academic Year Hours Earned: ____________________________
Requested semester/Quarter/Term(s): ___________________
_________________________________________________________
Cum GPA: ______________ Total Hours Earned: _______
Term Count: ___________
Suspended:
NO
YES After: __________________
Additional Action Needed at Time of Update:
Comments:
Disapproved
Approved For:
____________________________________________________
Reinstatement Approved For:
________________________________________
_____________
SIGNATURE (Approval Authority) DATE
For assistance with this form, send an email to [email protected].
Revised 09/21/2023 Page 2
INSTRUCTIONS for Request for Exception Form
IT WILL TAKE A MINIMUM OF 4 TO 6 WEEKS TO PROCESS THIS REQUEST - IF IT IS COMPLETE WHEN IT IS RECEIVED
Requirements to maintain TOPS eligibility: (1) enroll for the first time as a full time student no later than the semester immediately following the one year anniversary of high school graduation;
(2) enroll as a full time student each semester; (3) remain continuously enrolled during each semester; and (4) earn at least 24 hours during each academic year.
Section A. Insert all information requested. Your email address and your phone numbers should be the best numbers at which you can be reached in case additional information is required for
your request for exception. Your LOSFA ID number can be found on any correspondence that you have received from LOSFA regarding your TOPS award. If you have not yet signed up for
an account on the Student Hub, you should do so at https://mylosfa.la.gov/applications/student-hub/. This will allow you to view your TOPS status, including your exception status, at any time.
Section B. Check the box that corresponds to the program for which you need an exception.
Section C. Check the box that corresponds to the type of exception you are requesting. Refer to the chart below to determine the type of exception your circumstances support.
Section D. Insert the semester/quarter/term that you did not enroll or resigned or you were not able to earn the hours you needed to meet the 24 hour requirement.
Section E. Sign the form.
Section F. Date the form.
You MUST provide (1) the completed and signed Request for an Exception form, (2) your personal letter explaining the circumstances that lead to your need for an exception, and
(3) the required supporting documents listed for your circumstances in the chart below. Email the completed form, your personal letter, and required supporting documentation
to TOPS.exceptions@la.gov. If you do not have all required supporting documentation, you should submit the Request for Exception form without the documentation and include
a statement in your personal letter that you are in the process of obtaining the necessary documentation. Do NOT send us your social security number. You can also submit your
request via FAX to (225) 208-1618 or by mail to LOSFA, Legal – Exceptions Section, 602 North 5th Street, Baton Rouge, LA 70802. LOSFA must receive the completed Request for
Exception form no later than the deadline that is printed at the bottom of the cancellation notice that was emailed to you. If you have not received a cancellation letter, submit your Request
for Exception form as soon as possible after the event or circumstance that supports your request. If your request is received after the deadline on the notice of cancellation, it will not be
considered. Keep a copy of what you send to support your request for exception for your records.
CIRCUMSTANCES WARRANTING EXCEPTION TO THE INITIAL, FULL-TIME, AND CONTINUOUS ENROLLMENT REQUIREMENTS AND TO THE 24 HOUR REQUIREMENT
CODE & TYPE
CIRCUMSTANCES
REQUIRED SUPPORTING DOCUMENTS
MAXIMUM*
1 Parental Leave
You are/were pregnant or caring for a
newborn or newly-adopted child less than
one year of age.
(1) a written statement from a doctor of medicine who is legally authorized to practice certifying the date of diagnosis of
pregnancy and the anticipated delivery date, or the actual birth date, OR
(2) a copy of the hospital’s certificate of live birth, OR
(3) a copy of the official birth certificate or equivalent official document, OR
(4) written documentation from the person or agency completing the adoption that confirms the adoption and date of adoption.
(5) if you are not the custodial parent of the child, documentation of the adoption/custodianship as well as documentation
evidencing that you are assisting in the care of the child, which may include, but is not limited to, a letter from the
custodial parent confirming that you provide care, evidence of child support payments made, and/or evidence of bills paid
by you for the benefit of the child.
Up to the equivalent of
one full academic year
per pregnancy.
2 Physical
Rehabilitation
Program
You are/were receiving physical
rehabilitation in a program.
(1) a statement of reason for the rehabilitation, the necessity of withdrawing, dropping hours, etc., the semester(s) involved
and any other information or documents that may be relevant to your request; and
(2) a written statement from a qualified medical professional confirming the rehabilitation and the beginning and ending
dates of the rehabilitation.
Up to 4 consecutive
semesters (6
consecutive quarters)
per occurrence.
3 Substance
Abuse
Rehabilitation
Program
You are/were receiving substance abuse
rehabilitation in a program prescribed by
a qualified professional and administered
by a qualified professional.
(1) a statement of the reason for the rehabilitation, the necessity of withdrawing, dropping hours, etc., the semester(s) involved
and any other information or documents that may be relevant to your request; and
(2) a
written statement from a qualified professional or from the director of a substance abuse rehabilitation
facility confirming the rehabilitation and the beginning and ending dates of the rehabilitation.
Up to 2 consecutive
semesters or 3
consecutive quarters.
Available only once.
4A Temporary
Disability – Self
You are/were recovering from an
accident, injury, illness, or surgery.
(1) a statement of your disability, the necessity of withdrawing, dropping hours, etc., the semester(s) involved, and any other
information or documents that may be relevant to your request
(2) a written statement from a qualified medical professional certifying the existence of a temporary disability, the dates of
treatment, and opinions as to the impact of the disability on your ability to attend school.
Up to two full
academic years
4B Care of
Immediate
Family Member
(who has a
Temporary
Disability)
You are/were providing continuous care
to your spouse, dependent, parent,
stepparent, custodian (guardian) or
grandparent due to their accident, illness,
injury or required surgery.
(1) a statement of your family member’s disability, the family connection, the necessity of withdrawing, dropping hours,
etc., the semester(s) involved, and any other information or documents that may be relevant to the your request
(2) a written statement from a qualified professional of the family member’s temporary disability and the beginning and
ending dates of treatment; and
(3) a statement from a family member or qualified professional confirming the care you gave; and
(4) a written statement from a parent or other documentation confirming the family connection.
Up to a maximum of 2
consecutive semesters
(3 consecutive
quarters).
*An exception will NOT automatically be granted for the maximum allowed. An exception will only be granted for those semesters for which you provide supporting documentation.
Revised 09/21/2023 Page 3
INSTRUCTIONS for Request for Exception Form
4C Temporary
Disability –
Mental Health
You are/were seeking assistance
concerning your mental health.
(1) a statement of your disability, the necessity of withdrawing, dropping hours, etc., the semester(s) involved, and any other
information or documents that may be relevant to your request.
(2) a written statement from a qualified professional or a clergyman certifying the existence of a temporary disability, the
dates of treatment, and opinions as to the impact of the disability on your ability to attend school.
Up to two full
academic years
5 Permanent
Disability
You are permanently disabled in a manner
that prevents you from attending classes
on a full-time basis.
(1) a description of the disability and an explanation why the disability prevents you from attending classes full-time, and
(2) a written statement from a qualified professional stating the diagnosis of and prognosis for the disability, stating that the
disability is permanent, and opining why the disability restricts the student/recipient from attending classes full-time
despite medications, accommodations, therapy and/or treatment.
Up to the equivalent of
8 full-time semesters
of postsecondary
education in part time
semesters.
6 Exceptional
Educational
Opportunity
You are/were enrolled in an internship,
residency, cooperative work, or
work/study program or a similar program
that, in the written opinion of your
academic dean, will enhance your
education.
(1) a written statement from the college/school official that you are a student at the school/college and that the program is
offered or sponsored by the college/school, or
(2) a statement from the dean of your college or the dean’s designee or from the Director of the your program of study that
the program is related to your major and will enhance your education.
The statement must include the dates of leave of absence, the semester(s) or number of days involved, and the beginning
and ending dates of the program.
Up to 4 consecutive
semesters (6
consecutive quarters).
7 Religious
Commitment
You are a member of a religious group
that requires you to perform certain
activities or obligations to be a member of
that group, which necessitate taking a
leave of absence from school.
(1) a statement explaining the necessity of withdrawing, dropping hours, etc.; the semester(s) or number of days involved;
and the length of the religious obligation, and
(2) a written statement from your religious group’s governing official documenting the group’s requirement, the necessity of
the leave of absence, and dates of the required leave of absence.
Up to 5 consecutive
semesters (8
consecutive quarters).
8 Death of
Immediate
Family Member
Your spouse, parent, stepparent, custodian
(guardian), dependent, sister, brother,
stepsibling or grandparent dies.
(1) a copy of the death certificate, or
(2) a doctor’s or funeral director’s verifying statement, or
(3) a copy of the obituary published in the local newspaper, and
(4) if your last name is different from the deceased and you are not listed in the obituary, a written statement from a parent
or other documentation explaining the family connection between the student and the deceased.
1 semester or 2
consecutive quarters
per death.
9A Military Service
- Self
You are/were in the United States Armed
Forces Reserves or National Guard called
on active duty status or are/were
performing emergency state service or
enlisted or reenlisted are/were on active
duty as a member of the regular United
States Armed Forces.
(1) a statement of the dates of the required leave of absence, necessity of withdrawing, dropping hours, etc.; the semester(s)
or number of days involved; and the length of duty (beginning and ending dates), and
(2) a written certification from the military including the dates and location of active duty, or
(3) a copy of your military orders or separation forms showing dates of active duty.
Up to the length of
active duty service.
9B Military Service
- Spouse
Your spouse is in the United States
Armed Forces Reserves or National
Guard and is called on active duty status
or is performing emergency state service
with the National Guard or enlists or
reenlists and enters on active duty as a
member of the regular United States
Armed Forces
(1) a statement of the dates of the required leave of absence, necessity of withdrawing, dropping hours, etc., the semester(s)
or number of days involved, and the length of duty (beginning and ending dates); and
(2) a copy of your marriage license;
(3) a written certification from the military including the dates and location of active duty of your spouse; or
(4) a copy of the military orders or other military documents confirming the military service of your spouse.
Up to two consecutive
semesters
10 Transfer -
Selective
Enrollment
Program
You completed the prerequisite program
requirements for transfer to a Selective
Enrollment Program.
(1) a statement of the semester(s) affected and the selective enrollment program in which you intend to enroll, and
(2) a written statement from the dean of the college or the dean’s designee certifying that you have or will complete your
prerequisite requirements for transfer to the Selective Enrollment Program, and
(3) the date you completed or will complete those requirements.
Up to 2 consecutive
semesters or 3
consecutive quarters.
11 Unavailability of
Courses
You are unable to enroll full time due to
the advanced coursework required, the
necessity of earning credits in pre-
requisites before moving on to the next
block of courses, and/or the unavailability
of course due to limited course offerings.
Requirement: you have earned credit for
at least 75% of the courses required to
complete your degree.
(1) an explanation as to why you are unable to enroll full time, college transcripts, a description of your major, the total hours
required to graduate, the structure of courses; and
(2) a letter from your academic counselor or from the dean or director of your program of study explaining the course structure
and certifying that you have earned credit for at least 75% of the courses required to complete your degree and you are
unable to enroll full time due to this structure
*An exception will NOT automatically be granted for the maximum allowed. An exception will only be granted for those semesters for which you provide supporting documentation.
Revised 09/21/2023 Page 4
INSTRUCTIONS for Request for Exception Form
12 Natural Disaster
You are unable to enroll in school, to
maintain continuous enrollment in school,
or to earn the required annual hours due to
the fact that you or your family live in a
region of the state of Louisiana that is
declared a natural disaster by the
Governor of the state.
(1) A written statement detailing the natural disaster’s impact on you or your immediate family (mother, father, custodian,
siblings and/or spouse and children), which prevented your from meeting the continuation requirements, including the
length of the impact; and
(2) Documentation corroborating your statement (examples: photographs of damage; insurance documents, FEMA
documents, fire and/or police reports; statements from public officials; statements from family members or other persons
with actual knowledge; receipts and invoices for work done and materials purchases; a copy of a lease and statement from
lessor regarding the impact of the flood; etc.).
Up to two consecutive
semesters (three
consecutive quarters)
13 Exceptional
Circumstances
(See Note 1 Below)
You have/had circumstances that are not
listed above that are exceptional and
are/were beyond your immediate control
that caused you not to enroll or fully or
partially withdraw from college or
prevented you from earning 24 hours.
(1) Submit a statement in a sworn affidavit signed by you in the presence of a notary detailing the circumstances that
prevented you from completing the requirements to keep your TOPS award and explaining why you believe that the
circumstances are exceptional and beyond your control; and
(2) Submit documentation to corroborate your statement of the exceptional circumstances.
Up to 2 consecutive
semesters or 3
consecutive quarters.
14A COVID 19 -
Fall 2020 –
Summer 2022
You are unable to enroll in school, to
maintain continuous enrollment in school,
or to earn the required annual hours due to
circumstances related to the COVID-19
pandemic as follows:
i. You struggle with on-line instruction; or
ii. Full time enrollment in on-line
instruction is not conducive to your
major/course of study; or
iii. You do not have appropriate
infrastructure, such as internet access,
sufficient bandwidth for the number of
people attending school/working from
home, etc., to attend classes on-line, or
iv. Your parent(s) were unable to work,
lost their employment, or worked
reduced hours due to mitigation
measures implemented to prevent the
spread of COVID 19
(1) Submit a personal letter detailing the circumstances that prevented you from completing the requirements to keep your
TOPS award, and:
i. If requesting an exception based on 14A.i. please provide a signed letter from a parent and/or a letter from an
academic advisor or dean at your school stating that you struggle with on-line enrollment; or
ii. If requesting an exception based on 14A.ii. please provide a letter from an academic advisor or dean at your school
explaining that full time enrollment in on-line instruction is not conducive to your major/course of study; or
iii. If requesting an exception based on 14A.iii. please provide a signed letter from a parent or other documentation
verifying that you do not have the appropriate infrastructure at home to attend courses on-line; or
iv. If requesting an exception based on 14A.iv. please provide a signed letter from your parent/parents and a letter
from their employer stating that your parent/parents were unable to work, lost their employment, or worked
reduced hours due to mitigation measures implemented to prevent the spread of COVID-19.
Available for the fall
semester/quarter of
2020 through the
summer semester of
2022/summer quarter
2022
14B COVID 19 -
Fall 2023 –
Summer 2024
You are unable to enroll in school, to
maintain continuous enrollment in school,
or to earn the required annual hours due
to circumstances related to the COVID-19
as follows:
i. You have been diagnosed with
COVID19; or
ii. A member of your family with whom
you reside has been diagnosed with
COVID-19; or
iii. You were exposed to COVID-19 and
must adhere to COVID-19 quarantine
protocols; or
iv. you live with or provide care to a
family member who is at risk for
severe complications if they contract
COVID-19.
(1) Submit a personal letter detailing the circumstances that prevented you from completing the requirements to keep your
TOPS award, and:
i. If requesting an exception because you or a member of your family with whom you live has been diagnosed with
COVID-19, please provide a written statement of diagnosis from a qualified health care provider or a pharmacy.
If you do not have a written statement of diagnosis or the affected individual tested positive on a home COVID-
19 test, you must provide a sworn affidavit from a family member other than the affected individual attesting to
the positive COVID-19 test; or
ii. If requesting an exception because you were exposed to COVID-19 and you must adhere to COVID-19
quarantine protocols, please provide a sworn affidavit from you attesting that you have been exposed to COVID-
19 and a copy or link to your college or university’s policy regarding such exposure; or documentation of a
notification from a public health authority, your postsecondary institution, or other reliable source notifying you
of exposure; or
iii.
If requesting an exception because you live with or care for a family member who is at risk for severe
complications if they contract COVID-19, please provide a letter from a qualified health care provider attesting
that you live with or provide care for a family member who is at high risk for severe complications if they contract
COVID-19.
Available for the fall
semester/quarter of
2023 through the
summer semester of
2024/summer quarter
2024.
*An exception will NOT automatically be granted for the maximum allowed. An exception will only be granted for those semesters for which you provide supporting documentation.
