Georgia State University-Dunwoody-SSS-Application Form

Instructions

Thank you for your interest in TRiO. Below, you will find information helpful to understanding the application process. Read them completely. Understand that these guideline requirements are established by the federal government – U.S. Department of Education.

Eligibility Requirements:
- A First Generation collge student, a PELL Grant recipient (low-income), or a registered student with
Disability Services
-Take most or all of your courses at the Dunwoody Campus of Geogia State University
- Be a U.S. Citizen or Permanent Resident
1. Turn in completed required forms
  • Application Enrollment Form
  • Income Verification (Dependent or INDependent)
  • Disability Documentation- Collegiate level (if applicable)
2. Copy of Permanent Resident card (if applicable)
3. Copy of Federal Tax form 1040/1040A/1040EZ from the Previous Year
TRiO will conduct an initial screening of your documentation. If you meet the eligibility criteria, you will be invited for a TRiO Intake session which is an in-person appointment with a TRiO staff member. The purpose of an intake allows a student to communicate their individual needs to staff and is an opportunity to show the connection of their needs to services the program provides. Lastly,TRiO will notifiy students when they do not meet eligibility.
Semester of Application*

FallSpringSummer
Year of Application*

Personal Data
Name*

First NameLast Name
GSU Panther ID#*
Social Security Number (For Federal Reporting Purposes Only)*
999-99-9999
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemale
Local Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
(999)999-9999
Cell Phone Number*
(999)999-9999
GSU Panthermail email*
example@example.com
You must activate your GSU Panthermail student email account. (ALL university correspondence is sent to your Panthermail Account)
Major*
Estimated Semester/Year of Graduation*
I take the majority of my classes on which campus*
I am a*
Ethnicity*
I am a former TRiO participant (SSS, UB, EOC, TS)*

YesNo
School*
English is my second language*

YesNo
Primary Language*
How did you hear about TRiO?*
Are you planning to graduate from GSU Perimeter College with an associate's degree?*
If yes, do you plan to transfer to a 4-year college or university?*

If no, will you be*

Entering the workforce for full-time employment?Other

	Institution Name
1
2
3

Statement of Interest
Please explain why you are interested in the TRiO program based on your particular academic needs for services and how this program can help you achieve success toward graduation.

Release of Information
I hereby apply for services in the TRiO Student Support Services Center. I certify that all information supplied by me is correct. I give permission to the TRiO Student Support Center staff to check my financial aid and I will provide financial information. I give consent for my information, including my name, picture, graduation status, college, major, and any awards or scholarships that I receive to be used by the TRiO staff in publications to promote the success of TRiO students. I authorize the release of my student academic and financial aid records for the program director to use for reporting purposes to the Department of Education.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Please Read Disclaimer: The Application Enrollment form, a copy of your 1040/1040EZ/1040A form from your current tax year, the signed verification of income form, and official disability documentation MUST be received by the TRiO office before a pre-screening of eligibility for services occurs. You will either receive notification via phone and/or email to schedule an INTAKE appointment if you meet
the eligibility requirements or be notified that you do not meet requirements for the program.

Verification of Income
Dependency Status

Independent student means that neither one of your parents claim you on their taxes. Choose here.Dependent student means that one or both of your parents claim you on their taxes. Choose here.
NOTE: Complete this form only if you filed your own taxes.
Student Name

First NameLast Name
ID#
IMPORTANT: TRiO SSS is funded by the United States Department of Education. Information provided will be utilized to determine eligibility for the program and is kept confidential by program staff.

Please answer the following items related to your household income using information reported on your most recently filed tax return.
Number of people in your household (including yourself)
Your Taxable Income as reported on your most recently filed tax return
(Line 6 – 1040 EZ or Line 27 – 1040A or Line 43 - 1040)
I did not file a tax return last year

(please check if it applies)
I, {studentName}, certify that the information I have provided regarding the size of
my family and taxable income is true to the best of my knowledge.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Required: Please provide a copy of Income Tax Form 1040/1040EZ/1040A

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NOTE: Complete this form only if your parent or guardian claimed/filed you on their taxes.
Student Name

First NameLast Name
ID#
IMPORTANT: TRiO SSS is funded by the United States Department of Education. Information provided will be utilized to determine eligibility for the program and is kept confidential by program staff.

Please answer the following items related to your household income using information reported on your most recently filed tax return.
Number of people in your household (including yourself)
Your Taxable Income as reported on your most recently filed tax return
(Line 6 – 1040 EZ or Line 27 – 1040A or Line 43 – 1040)
I did not file a tax return last year

(please check if it applies)
I, {studentName70}, certify that the information I have provided regarding the size of my family and taxable income is true to the best of my knowledge.
Parent Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Required: Please provide a copy of Income Tax Form 1040/1040EZ/1040A

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