Community College Of Baltimore County-SSS-Application Form

PARTICIPANT APPLICATION

Community College of Baltimore County-Catonsville-SSS
Student Support Services (SSS)
Community College of Baltimore County Catonsville
SSRV 160
800 South Rolling Road
Catonsville, MD 21228
443-840-4132
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*

MonthDayYear
mm-dd-yyyy
CCBC Student ID #*
Name*

FirstMILast
Address*

Street Address

Unit/Apt. #

CityState

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

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemaleX
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
EDUCATIONAL STATUS
Degrees earned at previous college?*

Associate'sBachelor'sOtherOther
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
CCBC INFORMATION
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
LEARNING OR PHYSICAL DISABILITY (optional)
Do you have a documented disability?*

YesNo
If yes, have you submitted documentation to Accessibility Service Office?*

YesNo
Tell us why you want to participate in the program. *
Income Verification Form

STUDENT INFORMATION:
Name

First NameLast Name
ID
STUDENT CONSENT:

By My signature below, I authorize and direct Community College of Baltimore County to:
1. Verify my family's income using Federal Tax Information (FTI) data from my Free Application for Federal Student Aid (FAFSA), for purpose of verifying my eligibility to participate in TRIO programs.
2. Verify my family's non-filing status using Federal Tax Information (FTI) data from my Free Application for Federal Student Aid (FAFSA), for purpose of verifying my eligibility to participate in TRIO programs.
3. 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 Balitmore 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(I)(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 Education Rights and Privacy Act.
Student Signature

Clear
Date

MonthDayYear
Date
Parent/Legal Guardian Signature

Clear
(if Student is considered a dependent student)
Date

MonthDayYear
Date
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, Academic Advisement, Enrollment Services permission to release my documentation to TRIO Student Support Services.
Signature*

Clear
TRIO Student Support Services Programs are 100% funded by the U.S. Department of Education. Federal funds for the 2020-2025 grant period for
SSS-Catonsville are $1,463,215.00

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.

PARTICIPANT APPLICATION