Georgia State University-Clarkston-SSS

TRIO Student Support Services Participant Application

Income Verification
To complete the application and admission process, the following information must be provided by the student:

♦ Signed Federal 1040 Tax Forms (If you are under 24 years of age and considered dependent according to Federal Student Aid, you must submit your parents' tax forms.)

OR

An official document that verifies your current household income status (i.e. letter stating unemployment, TANF, SSI, benefits etc.) and a copy of your financial aid form (i.e. your FAFSA) that you have submitted to the Federal Education Department that has your income information included. Please note: if income information is not on your FAFSA form, the form will not be acceptable!

♦ Official Disability documentation from a medical, federal, or state office, etc. (if applicable)
♦ First Generation Verification form (If applicable, this form is included in the packet)
♦ Complete entire application and thoroughly explain why you feel you need the services of TRIO Student Support Services in the "Statement of Interest" section on page 3 of this application

NOTE: Please be assured your privacy is of the utmost importance to us. As such, all submitted information (i.e tax documents, financial information, medical documentation, etc.) will be used solely to determine eligibility. All of your information will be treated in a strict confidential manner and stored in a secure location. For more information regarding privacy matters, please contact the office of TRIO Student Support Services at 678-891-3145.
Tax Forms or an official document that verifies your current household income status

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Official Disability documentation from a medical, federal, or state office, etc. (if applicable)

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As a federally funded program, TRIO SSS is required to provide documentation of a student's eligibility for the program to the U.S Department of Education. Please select an option below to use to verify your income eligibility.

Please complete only ONE of the sections below to indicate your chosen method of income verification. If you are classified an independent student, please use your own income information. If you are a dependent student, please use you parent/guardian's income information.
Did you or your parents (if dependent) file a Tax Return?

Filed a Tax ReturnDid NOT File a Tax Return
Filed a Tax Return
Please indicate your tax year filed:*
Taxable Income for the most recent tax year*
Form 1040, line 11b OR 15; Form 1040-SR, line 11b
Number of members in household included on this tax return*
Student Signature:*

Clear
Date*

MonthDayYear
Date
Parent Signature:*

Clear
Date*

MonthDayYear
Date
By signing this document section, I hereby certify that the information provided above is valid, non-fraudulent, and accurate.
If you choose to upload any official documents to verify your household income status, you can below. Official documents are 1040, 1040A, or 1040EZ Tax Form from the previous year signed and dated, a letter stating unemployment, TANF, SSI, Military Benefits, or a copy of your SAR (i.e., from your most current submitted FAFSA). Please note: If you are under 24 years old, you are considered dependent and must submit your parent/guardian's information. YOU MUST SUBMIT SOME INCOME INFORMATION in Option 1 or 2 or upload an official document! If NO income information is submitted, the application will be marked invalid and incomplete.

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Note: Please be assured your privacy is of the utmost importance to us. All submitted information (i.e., tax documents, financial information, medical documentation, etc.) will be used by TRIO Student Support Services (SSS) solely to determine eligibility. Your information will be kept confidential and stored in a highly secure location.

I understand that the TRIO SSS Staff adheres to all guidelines under the Federal Education Rights and Privacy Act (FERPA). I certify that the information provided on this application is correct to the best of my knowledge. I authorize TRIO SSS to access my financial, demographic, and academic information as a Perimeter College student. TRIO Student Support Services also has permission to use my data in Georgia State University, and the U.S. Department of Education reports.
Student Signature*

Clear
Date*

MonthDayYear
Date
I certify that the information provided on this application is correct to the best of my knowledge. I authorize Student Support Services to access my financial, demographic and academic information as a Perimeter College student. Student Support Services also has permission to use my data in reports to Perimeter College and the US Department of Education.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

First Generation Verification Form
If not applicable enter N/A in this section and continue to signature.

Dear SSS Administrator:
This is to certify that I(student's name) {studentsName} am eligible to participate in the TRIO Student Support Services program at Perimeter College under the first generation provision of the project, since neither of my parents/legal guardians, (mother's name or legal guardian) {mothersName} & (father's name or legal guardian) {fathersName} completed a bachelor’s degree. By signing this document, it is acknowledged that this statement is true and correct to the best of our knowledge.
Student's Name*

First NameLast Name
Mother's Name or Legal Guardian*

First NameLast Name
Father's Name or Legal Guardian*

First NameLast Name
Student's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy