Pitt Community College-SSS-Application Form

TRIO STUDENT SUPPORT SERVICES PROGRAM APPLICATION

General Information
Name*

First NameMiddle InitialLast Name
Student ID #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
mm-dd-yyyy
Date of Application*

MonthDayYear
mm-dd-yyyy
PCC Email Address*
example@example.com
Alternate Email Address*
example@example.com
Cell Phone*
(999)999-9999
Home Phone*
(999)999-9999
Preferred Method(s) of Contact (Check ALL that apply)*

EmailTextPhone CallMail
Emergency Contact*

First NameLast Name
Phone*
(999)999-9999
Relationship*

First Generation Status

Did either parent or guardian with whom you resided have a bachelor's degree prior to you turning 18? Please provide this information only for those parents/guardians living in your former household.*

	Yes	No
Mother/Female Guardian
Father/Male Guardian

Income Verification
Income Verification Option*

Option 1: Use My Financial Aid ApplicationOption 2: Provide a Statement of Family IncomeOption 3: Submit Income Tax Return (Keep upload box option)
Complete only 1 of the 3 sections below. Check the appropriate box to indicate your chosen method of income verification.
Income Verification Option*

Option 1: Income Tax Refund Included. I am including my parent or guardian's income tax return for last year with this application.Option 2: Financial Aid Application Included. I am including my financial aid application with this application.Option 3: Statement Including Family Taxable Income and Family Size. I/my parent of guardian filed an income tax return last year.
Option 1: Parent or Guardian's Income Tax Return

Cancelof
Option 2: Financial Aid Application

Cancelof
Option 3: The number of individuals currently living in my household and/or claimed as dependents (including myself) is
Option 3: My/my parent or guardian's taxable income for last year was
(Form 1040 line 43 or Form 1040A line 27). Please note that taxable income is different from gross or net income.
Income Verification Section

Please choose one of the following options to verify income eligibility:

Option 1: Provide a Statement of Family Income
I (or my parent/guardian) filed a tax return last year. I am providing the following information:

Use My Financial Aid Application

I authorize TRIO: Student Support Services to access and use my financial aid application to determine low-income eligibility.
Number of people currently living in the household (including yourself):
Total taxable income for last year (from you or your parent/guardian):
Option 3: Submit Income Tax Return
I am submitting a copy of last years income tax return for myself or my parent/guardian along with this application.
Upload the income tax return for yourself or your parent/guardian

Cancelof
Parent Signature (if younger than 18)

Clear

Consent Form
I would like to participate in the TRiO Student Support Services Program and receive the free services provided.

I hereby certify that the information provided in this application is accurate and complete to the best of my knowledge.

I give consent for the TRiO Student Support Services Program to access all of my student records at Pitt Community College, including both academic and financial records.

I understand that this information is confidential and will only be used for the purposes of my application to this program.
Applicant Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy