University Of Maine-Farmington-Foothills-UB-Eligibility Form

ELIGIBILITY ASSESSMENT FORM
This form should be completed by the parent(s) or guardian(s) of the student who is applying to Upward Bound. All information is confidential and is used to determine eligibility for Upward Bound. If you have any questions, please call your Upward Bound representative at 1-888-237-1667.
Student*

First NameMid. Init.Last Name
SS #
999-99-9999
Gender

MaleFemaleNonbinary or another genderDo not wish to report
Student's Address

Street or P.O. Box

Street Address Line 2

CityState

Zip Code
Home Phone #
Cell #
DOB

MonthDayYear
mm-dd-yyyy
Age
Student's E-mail Address*
example@example.com
Parent or guardian email
example@example.com
High School
Current Grade
County

SomersetAndroscogginFranklinKennebecOxfordOther
Is this student in the custody of the Department of Human Services?

YESNO
(If YES do not fill out the rest of this form. Go to the end, sign, and return to the U.B. office.)

List Every Person Living in the Same House as the Student

	List Every Name	List Every Person’s Relationship to the Student	Last Grade Completed: Grade School (GS 1-12) or College (C 1-4)	Place of Employment	Number of Hours Worked Per Week	Wage Per Hour	Total Weekly Income
1.
2.
3.
4.
5.
6.
7.
8.

If one parent (mother or father) is not living in the student’s home, enter that parent’s name and address below.
Mother's Name

First NameLast Name
Address

Street/P.O. Box)

Street Address Line 2

CityState

Zip Code
Father's Name

First NameLast Name
Address

Street/P.O. Box)

Street Address Line 2

CityState

Zip Code
Will Parent/Guardian file a federal income tax return for 2024?

YESNO
2024 Taxable Income
*You will find your Taxable Income listed on the following IRS tax form: Form 1040 – Line 15
If 2024 Taxable Income is not available upon completion, please provide 2023 Taxable Income
*You will find your Taxable Income listed on the following IRS tax form: Form 1040 – Line 15
Check (√) all other types of income received by or for any member of the household. Be sure you entered income from work of every person living in your home which you have listed.

a. TANFb. Supplemental Nutrition Assistance Program (SNAP)c. Soc. Sec. Disability Income (SSDI)d. Supplementary Security Income (SSI)e. Other Social Security (Specify by Name)f. Child Support Paymentsg. Alimonyh. Dividends or Interest
Are you eligible for free and reduced lunch?

YESNO
Are you a citizen of the United States?

YESNO
If NO, please indicate status and provide documentation

Legal AlienRefugee/AsyleeLawful Permanent ResidentOther
Have there been recent changes in your financial situation?

YESNO
If YES, please explain.
Do you expect any changes?

YESNO
If YES, please explain.
What is the student’s racial/ethnic background: (optional)

Black or African AmericanAmerican Indian/Alaskan NativeHispanicAsianNative Hawaiian or Pacific IslanderWhite
Do you identify as Hispanic/Latino:

YesNo
What is the student's racial background?

Black or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian or Pacific IslanderWhite
Do either of the student’s biological or adoptive parents have a bachelor’s degree or a 4 year college degree?

Yes, MotherYes, FatherNo, Neither
Name of College/University
Name of College/University
Does this student have a diagnosed disability?

YESNO
If YES, please describe disability:
I CERTIFY THAT THE INFORMATION REPORTED ON THIS STATEMENT IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, CORRECT, AND COMPLETE.
(Parent/Guardian Signature)

Clear
Relationship to the Student
Date Signed

MonthDayYear
mm-dd-yyyy
UMF Upward Bound

252 Main St.

Farmington, ME 04938

Web Address: https://www.umf.maine.edu/upwardbound/
Telephone: (207)778-7296
Toll Free: 1-888-237-1667

Non-Discrimination Notice

In complying with the letter and spirit of applicable laws and pursuing its own goals of diversity, the University of Maine System does
not discriminate on the grounds of race, color, religion, sex, sexual orientation, transgender status, gender, gender identity or expression, ethnicity, national
origin, citizenship status, familial status, ancestry, age, disability physical or mental, genetic information, or veterans or military status in employment,
education, and all other programs and activities. The University provides reasonable accommodations to qualified individuals with disabilities upon request.
The following has been designated to handle inquiries regarding non-discrimination policies: Office of Equal Opportunity and Title IX Services, 5713 Chadbourne Hall, Room 412, University of Maine, Orono, ME 04469-5713, 207.581.1226, TTY 711 (Maine Relay System). Web Address: https://www.maine.edu/equal-opportunity/

ELIGIBILITY ASSESSMENT FORM