Austin Peay State University-EOC

Austin Peay State University-EOC

Social Security #
999-99-9999
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Apt #

CityState

Zip Code
Email*
example@example.com
Daytime Phone*
(999)999-9999
Date of Birth*

MonthDayYear
mm-dd-yyyy
Are you currently a high school senior?*

YesNo
Please list your school name*
Gender*

FemaleMale
Marital Status*

MarriedSeparatedSingleDivorced
Household Size (Including yourself & Dependents)*
Employment

Full timePart timeUnemployed
Are you a U.S. Citizen?*

YesNo
If No, Eligible non-citizen number: A
Please Select Military Affiliation

VeteranActive DutyVeteran SpouseActive Duty SpouseVeteran DependentActive Duty Dependent
Do you consider yourself to be Hispanic/ Latino?*

YesNo
Ethnic Background*

AsianBlack /African AmericanAmerican Indian /Alaska NativeWhiteNative Hawaiian /Other Pacific IslanderOther
Are you or have you been in one of these TRIO Programs?

Veterans Upward Bound (VUB)Upward Bound (UB)Student Support Services (SSS)Another EOC
Potential First Generation Student? (Check “yes” if neither of your parents earned a bachelors’ degree before you turned 18)*

YesNo

Type a question

Rows	Pell Grant	Loans	Total Aid
1.

CLARKSVILLE/FT. CAMPBELL
EDUCATIONAL OPPORTUNITY CENTER

DOCUMENTATION OF INCOME STATUS

The U.S. Department of Education requires that the Clarksville/Ft. Campbell Educational Opportunity Center provide income documentation on each participant who will receive assistance by our staff. This information is used for statistical purposes only and is strictly confidential.
If you are unsure on how to answer this question, please feel free to contact us for clarity before responding

I certify that, to the best of my knowledge, I meet the Federal low income guidelines
A checkmark in any of the areas below identifies you as meeting the Federal low income guidelines:

AFDC/Families FirstFood StampsTennCare with no monthly premiumTennCare/MedicaidAFDC/KTAP
Please state your total Taxable Income for

20232024
Taxable Income for year selected above
This information can be found on your income tax form:

2023 or 2024 Income Tax Forms

1040 Line 15

1040-SR Line 15
Please check

I certify that, to the best of my knowledge, I meet the Federal low income guidelines
I certify that, to the best of my knowledge, I meet the Federal low income guidelines*

YesNo
The EOC has my permission to obtain all necessary Financial Aid secondary and post-secondary information to enroll me into the program and monitor my progress.
The EOC has my permission to contact me through the following forms of communication

TextEmailPhoneMail
I give the EOC permission to access my educational records for tracking purposes, as required by the Department of Education.
I understand that the above information will be used statistically to evaluate
this project in reports to the U.S. Department of Education. I certify that all
statements made by me are true to the best of my knowledge and I agree to release my information statistically for the purpose of reporting to the U.S. Department of Education
Signature*

Clear
Student's Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy