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 be eligible for this program.)

How did you hear about the program?

Financial AidAdvisingInstructorOther

Today's Date

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*

mm-dd-yyyy

Gender

MaleFemaleNonbinary or another gender

Ethnicity (if more than one race, check all that apply)

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

Name:

First NameLast Name

Student ID:

STUDENT CONSENT:

By my signature below, I, {name}authorize and direct Community College of Baltimore County to:

A. Verify my family’s income 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.
B. Verify my family’s non-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.
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.

I agree that such verification described in options A and B 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.

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

Date

mm-dd-yyyy

Parent/Legal Guardian Signature (if Student is considered a dependent student)

Date

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

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