University Of Cincinnati-Blue Ash College-SSS-Application Form

University of Cincinnati
Student Support Services
PROGRAM APPLICATION

***You can’t spell success without SSS***

Demographic Information
Name*

First NameLast Name
Preferred Name (if different from above)
Today’s Date

MonthDayYear
mm-dd-yyyy
Referred by
M Number ID#*
UC E-mail address*
example@uc.edu
Cell Phone*
(999)999-9999
Alternate phone or email
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Hispanic Ethnicity*

NoYes
Race*

American Indian/Alaskan NativeAsianAfrican American/BlackNative Hawaiian/Pacific IslanderWhite

Income Verification
The TRIO Student Support Services program is a federal TRIO Program that requires documentation to certify a student’s eligibility in compliance with U.S. Department of Education regulations. All information provided to verify eligibility, inculding the infromation in this form, will be used solely for this purpose.

You can verify taxable income in two ways. Option 1 is to submit your 2024 signed Income Tax return (first page of 1040 form showing line 15) or Transcript (redact all social secruity numbers). Option 2 is to complete the Taxable Income statement below. Taxable income can be found on line 15 of Form 1040.

If you are a dependent student per FAFSA guidlines, please include your parent/guardian’s income information.
Are you a dependent student per the FAFSA guidelines?*

YesNo
Chosen method of income verification*

Option 1: Signed Income Tax Return or Transcript Included. I am including my/my parent or guardian’s signed income tax return or transcript for last year with this application.Option 2: Statement including Family Taxable Income and Family Size
Signed Income Tax Return or Transcript*

Browse Files

Cancelof
Please check one of the two statements below regarding your and/or your parents/guardians most recently filed federal income tax return and enter the requested income household size information:

I and/or my parents/guardians did not file a tax return for 2024I and/or my parents/guardians did file a tax return for 2024
Family Taxable/Earned Income*
Family Size *
I and/or my parents did not file a tax return for 2024, and I verify that the earned income and family size listed above is accurate.
I and/or my parents/guardians did file a tax return for 2024, and I verify that the taxable income (Line 15) and family size listed above is accurate.
Name

First NameLast Name
Student Signature*

Clear
Today’s Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Today’s Date*

MonthDayYear
mm-dd-yyyy

Program Authorization

If accepted into the UC SSS program, I (please initial)*

	Initials
Authorize program staff to obtain records or data pertinent to my participation from other campus offices and/or public agencies such as financial aid, admission, and academic records. I understand that the TRIO SSS staff adheres to all guidelines outlined under the Federal Education Rights and Privacy Act (FERPA).
Understand that such information will be kept confidential and will be used to evaluate my academic progress and determine appropriate services.
Understand that if my GPA falls below a 2.0 I will be placed on the TRIO SSS Academic Improvement Program which may require mandatory services. In addition, TRIO SSS will contact my professor(s) to receive progress reports.
Give permission to the TRIO SSS to divulge to any qualified person information deemed necessary to serve my academic and accommodation needs. Also, in case of a federal or state audit, I understand that my information may be shared.
Give permission to TRIO SSS staff and/or Student Ambassadors to contact me by phone, text message, mail, e-mail, or social media concerning issues involving services I am receiving.
Give permission for TRIO SSS to use photographs of me for marketing and other program-related publications.
If applicable, give permission to TRIO SSS Staff to speak with the Office of Disability Services on my behalf, and, in so doing, may obtain information regarding assistance I receive

Affidavit of Truth Statement and Release of Information

My signature bears witness that the information provided on this application is true to the best of my knowledge. I also understand that (1) omissions or misrepresentations on my part will automatically invalidate consideration by, acceptance to, or continuation in TRIO SSS; (2) An additional appointment and assessment is necessary to determine my acceptance into TRIO SSS; (3) Completion of this form does not guarantee that I will be selected as a TRIO SSS Scholar; and (4) If I am not an active participant in TRIO SSS, my status can be changed to inactive without my notification.
Student Signature*

Clear
Today’s Date*

MonthDayYear
mm-dd-yyyy