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

University of Cincinnati
Student Support Services
PROGRAM APPLICATION

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

Income Verification
TRIO SSS is federally funded through the U.S. Department of Education. As part of the eligibility requirements, we need to prove taxable income. This information is for the sole purpose of determining one of the eligibility criteria to participate in the TRIO-SSS Program. Please complete ONLY one of the three sections below to indicate your chosen method of income verification. If you are an independent student, please use your own income information. If you are a dependent student, please use your parent/guardian’s income information.
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: Financial Aid Application Included. I am including my most recent financial aid application with this application.Option 3: Statement including Family Taxable Income and Family Size
Signed Income Tax Return or Transcript / Financial Aid Application Upload

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Option 3: Statement including Family Taxable Income and Family Size

I, {name}, {i___} file an income tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is {numberOf}. My annual taxable income is approximately ${annualTaxable}. I am unable to produce any other financial information verifying my current taxable income. *Please note that taxable income is different from adjusted gross or net income.
Name

First NameLast Name
I ___ file an income tax return last year

diddid not
Number of individuals living in your household
Annual Taxable Income
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
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
Date*

MonthDayYear
mm-dd-yyyy