Fayetteville State University-SSS

  • Fayetteville State University

    1200 Murchison Road

    Fayetteville, North Carolina 28301

    (910) 672-1172

    sss@uncfsu.edu

    TRIO STUDENT SUPPORT SERVICES

    Student Support Services is a federally funded program that provides academic support services to a student meeting the grant guidelines. To be eligible for the program, you will need to demonstrate an academic need and provide the following: your taxable income from your 1040 tax documentation. All information provided will be held confidential and used for the TRIO SSS program purposes only. 

    ALL INFORMATION REQUESTED MUST BE COMPLETED FOR THE APPLICATION TO BE CONSIDERED.

    • STUDENT INFORMATION 

    • STUDENT INFORMATION

    • Date of Birth*
       - -
    • Preferred Method(s) of Contact (Check ALL that apply)
    • T-shirt Size
    • Class Level
    • Gender*
    • What is the Primary language spoken at home?*

    • Ethnic Background*

    • NEEDS ASSESSMENT 
    • Rows
    • If you indicated a need for tutoring please select which specific area(s):

    • I have participated in one of the following:
    • I have participated in the following (check all that apply):
    • MEDICAL INFORMATION 

    • MEDICAL INFORMATION

    • Are you registered with the Office of Disability Services?
    • Are you registered with the Office of Disability Services?
    • Do you have a physical impairment, medical condition or disability?*
    • Do you take any type of medication?*
    • Do you have any allergies?*
    • DEPENDENCY INFORMATION 

    • DEPENDENCY INFORMATION

    • Select one:*
    • ELIGIBILITY INFORMATION 

    • ELIGIBILITY INFORMATION

    • Awaiting Foster Care placement, living in a Foster home, residing in a Group home, an emergency/transitional shelter or a ward of the state.
    • DO YOU HAVE AN ASSOCIATED DEGREE?*
    • DID EITHER PARENT GRADUATE WITH A 4 YEAR DEGREE OR HIGHER?*
    • DID EITHER NATUTAL or ADOPTIVE PARENT GRADUATE WITH A 4 YEAR DEGREE OR HIGHER?*
    • PRIOR TO AGE 18, DID YOU REGULARY RESIDE WITH THE NATURAL or ADOPTIVE PARENT WITH A 4-YEAR DEGREE OR HIGHER?
    • INCOME VERIFICATION 

    • Please complete the information below, which verifies your family income for the last year.*Taxable Income*: This information can be found on Line 11b of your 1040 form.DO NOT USE YOUR ADJUSTED GROSS INCOME*

      Family Income: What is your family's *Taxable Income for last year? (not to include non-taxable income such as SSI, VA Disability, Child Support, TANF, etc.)

    • INCOME VERIFICATION (Family taxable income =150% of poverty level) Please complete the information below, which verifies your family income for the last year.*Taxable Income*: This information can be found on Line 11b of your 1040 form. DO NOT USE YOUR ADJUSTED GROSS INCOME* Family Income: What is your family's *Taxable Income for last year? (not to include non-taxable income such as SSI, VA Disability, Child Support, TANF, etc.) Federal TRIO Programs Current-Year Low-Income Levels | U.S. Department of Education What is your income Level?*

    • If you DO NOT submit a copy of your completed income tax form (1040, 1040EZ, 1040A), you will need to complete the information below, which serves as a verification of your family income for last year.

      *Taxable Income*: This information is located on tax forms (1040-line 43; 1040A-line 27; 1040EZ-line 6)

      *DO NOT USE YOUR ADJUSTED GROSS INCOME*

    • Do you receive any of the following:*

    • Certification

      As evidence of my signature below, I hereby certify that all the information I have furnished is correct and true to the best of my knowledge.

    • Please answer the following questions. Your answers will help us assess your motivation and preparation for academic success.

    • Clear
    • Date Signed*
       - -
    • Clear
    • Date Signed
       - -
    • STUDENT CONTRACT 

    • Fayetteville State University

      Student Support Services

      Student Contract

      I understand that the Student Support Services Program is a federally funded program, and that my selection to participate in the program is based on my meeting the federal eligibility criteria.

      · As a SSS Participant I agree...

      • To actively participate in the Student Support Services Program, which is designed to provide the following services: tutoring, counseling, academic support workshops, information regarding financial literacy, and graduate school preparation which will help me, achieve success during my tenure here at this institution.
      • To meet with my assigned SSS Advisor at least 1 time a semester.
      • To actively participate in SSS Workshops; attend at least 2 workshops each semester which will help me achieve my academic goals.
      • To arrive on time to all scheduled tutoring sessions with prepared class assignments, textbooks, and notes for each tutoring session.
      • To meet with my advisor during mid-term advisement to review my academic status.
    • Media Permission: I give TRIO SSS permission to include me in photographs, films, publications, or interviews as they pertain to TRIO Student Support Services and I understand that such pictures, films, or interviews may be used to promote or publicize TRIO Student Support Services events and/or program.
    • As a SSS Participant I agree...

    • I have read the above statements and understand that I will be put under a probationary period upon my initial intake into the program which may exceed two semesters of my enrollment at FSU.

      I will adhere to the contract by signing below:

    • Clear
    • Date Signed*
       - -
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