Pitt Community College-SSS-Application Form

TRIO STUDENT SUPPORT SERVICES PROGRAM APPLICATION

Name

First NameMiddle InitialLast Name
Student ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Date of Application

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-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)
Emergency Contact

First NameLast Name
Phone
(999)999-9999
Relationship

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.

Rows	Yes	No
Mother/Female Guardian
Father/Male Guardian

Income Verification 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: 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: Use My Financial Aid Application

I authorize TRIO: Student Support Services to access and use my financial aid application to determine low-income eligibility.

Option 2: Provide a Statement of Family Income

I (or my parent/guardian) filed a tax return last year. I am providing the following information:
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)

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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy