Sam Houston State University-SSS

First NameMiddle InitialLast Name

Number/Street/Apt. Number

Street Address Line 2

CityState

Postal / Zip Code

Number/Street/Apt. Number

Street Address Line 2

CityState

Zip Code

mm-dd-yyyy

MaleFemaleNot Listed

If you have trouble answering the Ethnicity & Race sections, please call our office at 936.294.1694

CitizenPermanent Resident/Refugee*Other

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Please contact the Disability Services Office to have them email triotss@shsu.edu to verify that you are registered with their office

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0-29 hours Freshmen30-59 hours Sophomore60-89 hours Junior90+ hours Senior

EC-6thMiddle School 4th-8thSecondary 9th-12th

ELARMATHMATH & SCIENCE

YesNoDid not reside with or receive support from mother before the age of 18

YesNoDid not reside with or receive support from father before the age of 18

If you checked “yes” to one or more of the above questions, you are considered an independent student.
If you checked “no” to all of the above questions, you are considered a dependent student.

Note: If you are a dependent student, but you are unable to provide your parent’s income information because they are incarcerated, you have left home due to an abusive family environment, you do not know where your parents are and are unable to contact them (and you have not been adopted), or any other special circumstance, please attach a letter stating your special circumstances to this application so that we can take it into consideration when determining your low-income eligibility.

Please attach the following with your completed application.

If you are a dependent student, we need your parents’/guardians’ proof of income from the previous-previous year. If you are an independent student, we need your proof of income from the previous-previous year.

You can submit one of the following as proof of income:

Your/your parents’ signed income tax return (1040) from last year or proof of unemployment
A statement signed by you/your parents stating your/their most recent taxable income and number of family members for that year

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(for detailed information on these requirements & instructions, go to: www.shsu.edu/triosss/