Lock Haven University Of Pennsylvania-SSS

TRIO Student Support Services Application

The following information is required to determine eligibility for the TRIO SSS program. Students who wish to participate in TRIO SSS must meet certain federal requirements. The information you provide will be kept confidential. The form must be completely filled out to be considered. If you have questions about the application, please email triosss@lockhaven.edu .

Please note: Per federal stipulations, the TRIO SSS grant serves only students designated as enrolled at LHU Main Campus.

Eligibility Verification
TRIO Student Support Services Eligibility Verification Section

Student Support Services (SSS) is a federally funded TRIO Program under the United States Department of Education. In order to qualify to participate, students must meet certain criteria. The questions asked on this page will aid in determining your eligibility for the LHU SSS Program.
Please complete all areas of the form completely in order to prevent any delays in your application.

In the event of a Department of Education program audit, participants and their
parents/guardians may be asked to provide copies of tax returns to document the financial information below.

Part I: First-Generation Verification
Select the option that best applies to you:*

I AM a first-generation college student because neither father/mother/guardian (biological or adoptive) with whom I reside did not receive a four-year (Bachelor’s) degree.I am NOT a first-generation college student because my father/mother/guardian (biological or adoptive) with whom I reside, did graduate with a four-year (Bachelor’s) degree from a college or university.
Part II: Financial Eligibility Verification

You are a dependent if you are claimed on your parents’/guardians’ tax return. Please complete the following information for you and your parent(s)/guardian(s).
Number of people in your household (including yourself)*
Parent(s)/guardian(s) 2022 TOTAL TAXABLE income (not adjusted gross income). This information can be found on line 15 of the federal 1040 tax form. (If parents/guardians filed “married filing separately” be sure to add taxable income from both tax forms). ($)*
Your 2022 TOTAL TAXABLE income (if applicable). This information can be found on line 15 of the federal 1040 tax form. ($)*
If applicable:

Check here if you are an independent student and DID NOT OR WILL NOT FILE a federal tax return for 2022.Check here if your parent(s)/guardian(s) DID NOT OR WILL NOT FILE a federal tax return for 2022.
Part III: Disabilities Verification
Have you ever had an IEP (Individualized Education Plan) and/or a 504 Plan?*

YesNo
Do you plan to register with the Office of Disability Services?(Disabilities can be learning, physical, or psychological.)*

YesNo
(If you have not registered, please contact The Office of Disability Services at Disability_Services@lockhaven.edu to complete the registration process. Lock Haven University is committed to providing equal access and full participation in programs to students with disabilities. Services, reasonable accommodations, support and advocacy will be designed to provide an accessible learning environment.)
Certification Statement
By signing below, I/we verify that the information on this form is accurate and complete to the best of my/our knowledge. This information will be kept confidential in a secure location and will be used only by TRIO SSS staff to verify eligibility for the services of the program.
To sign please use your mouse or touch screen.
Parent/Legal Guardian Signature*

Clear
Parent/Legal Guardian Name*

First NameLast Name
Date Signed*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Student Name*

First NameLast Name
Date Signed*

MonthDayYear
mm-dd-yyyy