University Of Wyoming-EOC

If you are 18 or over, not a high school student, and not fully admitted to or enrolled in college, please indicate your taxable income range below

Pick one:*

A) I am 18 or over, not a high school student, and not fully admitted to or enrolled in collegeB) I am fully admitted to or enrolled in college (currently taking courses)C) I am younger than 18 years of age and/or enrolled in high school

If you are fully admitted to or enrolled in college, please check all that apply

I am age 24 or older by December 31 of this year.I am married (or separated, but not divorced).I have legal dependents (other than a spouse or children) who live with me and who receive more than half of their support from me.I have children who receive more than half their support from me.I am a veteran of the Armed Forces of the United States or am currently serving on active duty in the Armed Forces for other than training purposes.I have been an orphan, in foster care, or a ward of the court after age 13.I am in legal guardianship as determined by a court of my legal residence at time of determination and/or an emancipated minor.I am a youth in transition or an unaccompanied youth.I have been determined to be an independent student by the financial aid office at my college.

If you are younger than 18 years of age and/or enrolled in high school, please check all that apply

I am married (or separated, but not divorced).I have legal dependents (other than a spouse or children) who live with me and who receive more than half of their support from me.I have children who receive more than half their support from me. .I have been an orphan, in foster care, or a ward of the court after age 13.I am in legal guardianship as determined by a court of my legal residence at time of determination and/or an emancipated minor.I am a homeless person or an unaccompanied youth.

If you DO NOT meet any criteria above, you will need a parent/guardian to verify family taxable income range below in order to receive services as an income-eligible participant.

Please indicate your taxable income range (not gross income) based on your previous year’s taxes.
(EOC Coordinators have taxable income worksheets to assist you in quickly calculating taxable income. You can also find taxable income listed on tax form 1040 Line 11b)

Taxable Income*

Family Size? (Total number of dependents claimed on taxes, including yourself)*

Certification: To the best of my knowledge, the information provided is accurate and complete. I authorize Educational Opportunity (EOC) to request and receive records related to my academic and degree status, financial aid status, and higher education registration and enrollment records for the purposes of tracking student academic progress, recordkeeping, and reporting purposes. I authorize the Educational Opportunity Center (EOC) to use this information for purposes of public relations, media events, recruitment, editorials, and possible referrals to other agencies for which I may be eligible.

Participant Signature*

Date signed

mm-dd-yyyy

Parent/Guardian Signature (if required)

Date signed

mm-dd-yyyy

I hereby certify that the signatures are made by the labeled person. Any false information may disqualify me/my child from acceptance into the program.*

Yes