Weber State University-STEM-SSS

APPLICATION TO THE STUDENT SUPPORT SERVICES STEM PROGRAM
WEBER STATE UNIVERSITY

STUDENT SUPPORT SERVICES STEM
WEBER STATE UNIVERSITY
STUDENT SERVICE CENTER: ROOM 265
Email Address: stephaniekawamura1@weber.edu

Additional Information
What is the highest level of your parents' or guardians' education?
Mother or Guardian's Name*

First NameMiddle NameLast Name
Mother or Guardian's Highest Level of Education*
Father or Guardian's Name*

First NameMiddle NameLast Name
Father or Guardian's Highest Level of Education*
Tax Filing Status (Do not email or fax taxes)
Have you filed federal taxes in the past two years?*

YesNo
If yes, please attach a SIGNED copy of your most recent 1040 U.S. Individual Income Tax Return form for the year 2022 or 2023.

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Are you considered a dependent student (under age 24, not married, no children, not an orphan, not a veteran, and not a military servicemember) for the 2022 or 2023 tax year?*

YesNo
If yes, please attach a SIGNED copy of your parent or guardian's most recent 1040 U.S. Individual Income Tax Return form for 2022 or 2023

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Please check if this applies to you

I was not required to file a federal tax form in 2023 because of low income or no income for that year, and no one else claimed me as a dependent on their taxes for the 2022 calendar year. (If you checked this box and you are a dependent, you must submit a signed statement from your parent/guardian explaining your financial status.)
Financial Status Explanation

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(Note: If your tax information does not accurately reflect your current financial situation, please attach a signed statement that explains the change to your income level.)
Signed Statement

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Documented Disabilities
Are you registered with Services for Students with Disabilities?

YesNo
If yes, please attach a letter from Services for Students with Disabilities.

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Authorizations
Authorization of Information/Statement of Authenticity

I authorize Weber State University or other universities I attended or am attending to release official transcripts, test scores, financial aid award information and other records to the Weber State University Student Support Services STEM program for educational planning purposes. I also authorize the above stated program to release these records to other institutions as they relate to my education planning.

I attest that the information I have provided is true and correct to the best of my knowledge. I attest that the documents I have presented for verification of eligibility are genuine and relate to me. I am aware that any false documents in connection with eligibility will be cause for my dismissal from the Student Support Services STEM program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Name*

First NameMiddle NameLast Name
Parent Signature (if student is under 18)

Clear
Date

MonthDayYear
mm-dd-yyyy
Confidentiality of Information

The personal information that is provided to the Student Support Services STEM program will be protected under the Family Educational Rights and Privacy Act of 1974. No one will have access to the information unless he or she works with or for the Student Support Services STEM program or is specifically authorized by the student in question to see the information. The information is necessary to help determine the success of participants in post-secondary education as authorized by the U.S. Department of Education

(20 United States code 1231a)

PLEASE NOTE: The application must be completely filled out with required documents attached (Taxes, Letter from Services for Students with Disabilities, if applicable). The College Inventory Survey must be taken prior to submission of the application to SSS. Permanent residents must attach a copy of their Resident Card.

Incomplete applications will not be accepted.