Community College Of Baltimore County-Essex-SSS

Student Support Services (SSS)
Student Services Center Room 143
7201 Rossville BLVD
Baltimore, MD 21237-3899
443-840-1544
essexstudentsupport@ccbcmd.edu

PARTICIPANT APPLICATION
Are you a U.S. Citizen or permanent resident?*

YesNo
(If you answer NO to this question Do Not Continue Completing this Application. You are not eligible for this program.)
How did you hear about the program?

Financial AidAdvisingInstructorOther
Today's Date

MonthDayYear
mm-dd-yyyy
Social Security #
999-99-9999
CCBC Student ID #*
90_______
Name*

FirstMILast
Address

Street

Unit / Apt. #

CityState

Zip Code
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
E-Mail Address (most used)*
example@example.com
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender

MaleFemaleNonbinary or another gender
Ethnicity (if more than one race, check all that apply)

1-American Indian or Alaskan Native2-Asian3-Black/African American4-Hispanic/Latino5-White6-Native Hawaiian or other Pacific Islander
Did your mother receive a Bachelor's Degree?

YesNo
Did your father receive a Bachelor's Degree?

YesNo
Do you currently receive Financial Aid?

YesNo
If you do not receive Financial Aid, why not?

SuspendedDid not applyDeniedPending
Are you and/or your parents willing to provide a copy of last year's tax return if requested?

YesNo
Degrees earned at previous college?

Associate'sBachelor'sNoneOther
Did you graduate from high school?

YesNo
If not, did you receive a GED?

YesNo
Have you been out of either high school or college for more than five years?

YesNo
Are you currently enrolled in at least 2 courses at CCBC?

YesNo
Do you plan to earn an Associate's Degree from CCBC?

YesNo
Certificate?

YesNo
Do you plan to transfer to a four-year institution?

YesNo
Tell us why you want to participate in the program.
Do you have a documented disability?

YesNo
If yes, have you submitted documentation to Disability Support Services?

YesNo
INCOME VERIFICATION FORM

STUDENT INFORMATION:
Name:

First NameLast Name
Student ID:
Please check one: *

Dependent Student (claimed by a parent or guardian on their taxes)Independent students (at least 24 years old by Dec. 31, orphan or ward of court at 18 years old, married, veteran or active duty military, have legal dependents, or homeless as a minor)
Attach tax return here:

Browse Files

Cancelof
If you are unable to attach a tax return, you or your parent/guardians MUST answer the questions below. If you have attached a tax return please enter "N/A" for questions 1 and 2.
If you are unable to attach a tax return, you or your parent/guardians MUST answer the questions below.
1. What is your family size according to your most recent tax return (spouse plus dependents listed)? *
2. Enter your taxable income as reported on the most recent tax return. Taxable income is less than your "adjusted gross income" and is listed further down on your tax return. An example is included below.*
3. I did not file taxes last year for the following reason (Choose one):

a. Social Securityb. Unemploymentc. Disabilityd. Veteran's Benefitse. Child SupportOther
4. If you did not file taxes, please list your total income from all sources for the previous year.
STUDENT CONSENT:

By my signature below, I, authorize and direct Community College of Baltimore County to:
- A. Utilize the information provided above as a statement of income and certify that the information furnished regarding the family size and taxable income is true to the best of my knowledge.
- B. If no income information is provided, to verify my family’s income and filing status using Federal Tax Information (FTI) data from my Free Application for Federal Student Aid (FAFSA), for the purpose of verifying my eligibility to participate in TRIO programs. This information may be provided to Student Support Services director, Student Support Services program coordinators, and other individuals employed by the Community College of Baltimore County and involved with the supervision and direction of projects funded under the Federal TRIO programs.
- C. Produce and release an un-redacted copy of the Institutional Student Information Record (ISIR) to my attention, for the purpose of verifying my eligibility to participate in TRIO programs.
To participate in TRIO programs as a “low-income individual,” my family’s taxable income cannot exceed 150 percent of the poverty level amount established by the Census Bureau. In absence of an IRS tax transcript, Community College of Baltimore County will utilize Adjusted Gross Income (AGI) information provided during FAFSA Completion.

To participate in TRIO programs as a “low-income individual,” my family’s taxable income cannot exceed 150 percent of the poverty level amount established by the Census Bureau.

I understand that the above records and information:
- 1. May include return information disclosed under section 6103(l)(13) of title 26; and
- 2. May only be used for the specific purpose outlined in this consent form and no other purposes.
It is my intent that this consent form be interpreted to the extent permitted by applicable law, including but not limited to the Internal Revenue Code, the Higher Education Act, and the Family Educational Rights and Privacy Act.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian Signature (if Student is considered a dependent student)

Clear
Date

MonthDayYear
mm-dd-yyyy
I hereby certify that all of the information I have provided on this application is accurate and true to the best of my knowledge. For the purpose of determining my eligibility for the program, I give the Offices of Financial Aid, Counseling, Enrollment Services permission to release my documentation to TRIO Student Support Services.
Student Signature

Clear
TRIO Student Support Services Program, Essex Campus, is 100% funded by the U.S. Department of Education. Federal funds for the 2020-2025 grant period are $1,681,695.

Note: According to Federal regulations, we cannot process your application without a SIGNATURE. All information provided will be kept confidential in accordance with FERPA policies.

INCOME VERIFICATION FORM