Zane State College-SSS-2021 Application Form

ZSC TRIO SSS Application

Do you have a need for any of the following services? (check all that apply)
Academic Tutoring

Other subject
Career
Academic Advising
Financial Aid
Financial Literacy
Transfer
Do you plan to transfer to a four-year program?

Please answer the following.

Rows	Yes	No
Are you at least 24 years old?
Do you have children or other dependents (other than a spouse) who receive more than half of their support from you?
Since you turned 13, were you ever an orphan, in foster care, or a ward of the court?
Before you turned 18, were you an emancipated minor or did you have a legal guardian?
Are you married or separated (not divorced)?
Are you a veteran who was on active duty and released under a condition other than dishonorable?
Are you serving on active duty in the military (other than training)?
Have you been determined to be an independent student by the ZSC Financial Aid office?

If you answered yes to any of these questions, consider yourself an independent student.
Complete this section if you answered yes to any of the questions under “Financial Eligibility” above.
Did you file a federal income tax return last year?
How many people are in your household (including yourself)?
If you filed last year, what was your adjusted gross income? (IRS Form 1040, line 11)
$ _______.00
If you filed last year, what was your taxable income? (IRS Form 1040, line 15)
$ _______.00
If you did not file last year, what was your total income?
$ _______.00
Did you have a taxable income last year?
Complete this section if you answered no to all of the questions under “Financial Eligibility” above.
Did your parents/guardians file a federal income tax return last year?
How many people are in your parents’/guardians’ household (including yourself)?
If your parents/guardians filed last year, what was their adjusted gross income? (IRS Form 1040, line 11)
$ _______.00
If your parents/guardians filed last year, what was their taxable income? (IRS Form 1040, line 15)
$ _______.00
If your parents/guardians did not file last year, what was their total income?
$ _______.00
Did your parents/guardians have a taxable income last year?
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature
Date

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

By signing below, I authorize TRIO Student Support Services (SSS) at Zane State College to access, copy, review, and discuss my academic records, including the following:
- Standardized test scores
- College transcript (including course grades and GPA)
- High school transcript (including course grades and GPA)
- Financial aid information (including information from the FAFSA)
- Course registration and tuition statements
- Disability documentation on file with Accessibility Services
This information will be used to determine my eligibility for TRIO SSS, monitor my academic progress, evaluate program effectiveness, fulfill program reporting requirements, and provide me with advising and advocacy services. I understand that my records will be kept confidential in accordance with federal privacy laws.

I give permission for the use of my name and photograph in TRIO SSS publications.

I consent to receive text messages at the cell phone number provided, and I understand that message and data rates may apply. I may request to no longer receive text messages from TRIO SSS.

The information I have provided in this application is true and accurate to the best of my knowledge. I understand that this application does not guarantee acceptance into TRIO SSS.
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Questions? Contact us!
trio@zanestate.edu • 740-588-4115

TRIO Student Support Services at Zane State College is 100% funded through a grant from the U.S. Department of Education, with an annual budget of $272,364.