Butte-Glenn Community College-SSS-Application Form

TRIO Student Support Services (SSS) - Classic Program Application
Application for Semester

FallSpring
Year
IMPORTANT! The Classic SSS program is designed for students who meet low-income or first generation eligibility. If you have a disability, or suspect you have a disability, please complete the Disabled SSS program application by going here.

Step 3: Education Information
1. Are you still in high school?

YesNo
2. Have you received your high school diploma or completed your GED?

Yes, received high school diplomaYes, completed GEDNone of the above at this time
3. Are you currently taking Butte College Courses?*

YesNo
4. How many college units have you completed as of today?

0 units1-12 units13-24 units24 units or above
5. If applicable, what is your college GPA?
6. How many units are you enrolled in this semester?

0-8 units9 units10-11 units12-15 units16 units or above
7. Do you plan on enrolling full-time next semester? (Full-time is 12 units or more, 6-9 units if authorized by DSPS as an accommodation)*

YesNo

8. Highest level of education completed by your birth or adoptive parents.*

	Unknown	Elementary (K-8)	High school graduate (9-12)	Some college	2-year college degree	4-year college degree (or higher)
Parent 1
Parent 2

* Please do not include stepparent or guardian education levels for this application
9. What is your Butte College major?
10. What year do you plan to graduate from Butte College?

202120222023Unsure at this time
10. What year do you plan to graduate from Butte College?
11. Do you plan to transfer to a four-year college or university?

YesNo
12. Please list all colleges or universities you are interested in attending after graduating from Butte College and explain your educational and/or career goals:

Step 4: Financial Aid Status and Eligibility Information
NOTE: If you, the student, are less than 24 years old and are considered a DEPENDENT student, your parent/legal guardian MUST also read and sign this application below.
1. Did you submit your Free Application for Federal Student Aid (FAFSA) for the academic year?*

YesNo
2. Which of the following were you awarded?

CA Promise Grant (formerly BOG)Cal GrantPELL GrantSEOGWork StudyButte College Promise ScholarshipOther
3. Are you a Veteran or a dependent using Veteran educational benefits?

YesNo
3a. If so, which ones?

Montgomery GI BillPost-9/11 GI BillChapter 35Other

4. Please answer the following questions to determine your dependency status*

	Yes	No
Were you born before January 1, 1996?
Are you married? (Answer "yes" if separated, but not divorced)
Do you have legal dependents (other than a spouse) who receive more than half their support from you?
Are you a veteran or serving on active duty (for other than training purposes) in the U.S. Armed Forces?
Are you, or prior to age 18, were you in foster care or a ward of the court?

4. Please answer the following questions to determine your dependency status
Are you over the age of 25?*

YesNo
Are you married? (Answer "yes" if separated, but not divorced)*

YesNo
Do you have legal dependents (other than a spouse) who receive more than half their support from you?*

YesNo
Are you a veteran or serving on active duty (for other than training purposes) in the U.S. Armed Forces?*

YesNo
Are you, or prior to age 18, were you in foster care or a ward of the court?*

YesNo
If you answered “yes” to any of the questions above, you are considered an INDEPENDENT student for financial aid reasons. You must provide YOUR taxable income. Skip to question #9 below.

If you answered “no” to ALL of the questions above, you are considered a DEPENDENT student for financial aid reasons. You must provide the taxable income of your birth or adoptive parents below.
Dependent Students
5. Family Size (This is the total number of people currently living in the household and supported by birth or adoptive parent(s), including children under the age of 24 who are away and attending college)
6. My family’s exact taxable** income for last calendar year. If family had no taxable income during calendar year enter “0."
7. Student Signature

Clear
7. Parent/Guardian Signature

Clear
*Parent Signature is required for students who are under 24 years old and/or have been determined to be dependent for financial aid reasons
If your parent/guardian is unavailable to sign the above income verification, check the box and enter below the address where we can mail a form for signature.

My parent/guardian is unavailable
Parent/Guardian Email Address
example@example.com
Income Verification (Choose one option)

**Please note: Taxable income is found on IRS Form 1040. This is NOT your Adjusted Gross Income (AGI)

To process your application, you MUST list taxable income on this portion of the application.

To find your taxable income review your or your parents 1040 tax forms and look at line 15, see below:
Independent Students
8. Family Size (This is the total number of people currently living in your household that you support financially)
9. My family’s exact taxable** income for last calendar year. If family had no taxable income during calendar year enter “0.”
10. Student Signature

Clear
Income Verification (Choose one option)

**Please note: Taxable income is found on IRS Form 1040 this is NOT your Adjusted Gross Income (AGI)

To process your application, you MUST list taxable income on this portion of the application.

To find your taxable income review your or your parents 1040 tax forms and look at line 15, see below:

Release Statement & Agreement
Please read carefully and then sign and date where indicated:

Privacy Act Information
In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services program under the Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services program. The principle purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties.
- By signing this application, I certify that all information provided above is true and accurate to the best of my knowledge.
- I understand that all information on this application, as well as that released from the school, will be held in strict confidence by the TRIO Student Support Services program staff.
- I authorize the release of academic records (e.g. copies of school transcripts, test scores) to the Butte College TRIO Student Support Services program in order to assess need/eligibility for program services, discern academic progress, evaluate the effectiveness of program activities, and fulfill program reporting requirements.
- I consent to the disclosure of any personally identifiable information as defined by FERPA of my education records to the Butte College TRIO Student Support Services program staff for the purpose of confirmation of the student’s postsecondary enrollment status as reported on the National Student Clearinghouse Student Tracker. This authorization will remain in effect for six years following admission into the TRIO SSS program.
- I authorize the release and exchange of student financial aid information from colleges and federal government to the TRIO Student Support Services program.
- I authorize the TRIO Student Support Services program to share and discuss information with school personnel, including Disabled Student Programs & Services as appropriate, in support of my academic success.
- I also give permission for the TRIO Student Support Services program to take photographs for identification purposes and during activities, and grant permission to use the student’s name, comments, and/or photos/videos for educational and/or promotional purposes.
- I understand that this authorization will remain in effect while the student is enrolled in the Butte College TRIO Student Support Services program or until written notice is provided to revoke the authorization.
Student's Name*

First NameLast Name
Student's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy