Southern Oregon University-SSS-2022 Application Form

Student Support Services

Parent Information
Do either of your parents or guardians have a 4-year college degree?*

YesNo
Financial Statement of need

(The TAXABLE income can be found on the U.S. Individual Income Tax Return - IRS form 1040 see line 15). NOTE: Family is defined as anyone who claims you as a dependent on their taxes regardless of your age - IF YOU ARE AN INDEPENDENT STUDENT – You must to enter your taxable income information for just yourself
Taxable Income Amount
Family Size*
Select one*

My family filed taxesMy family did not file a federal income tax return for the prior tax yearMy family had no taxable income for the prior tax year
What was your family’s taxable income in the prior tax year? *
My family’s total income was*
If you are a dependent student and submitted your parents information when you completed the FAFSA, they will need to verify the information above. Please have them review this information and sign the box below.

I, as the parent or legal guardian of the applicant, verify to the best of my knowledge, the annual taxable household income (answered above) are accurate. By typing my full name below, I am attesting to the truth of this statement.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear

Verification and Release of Information
All information I have submitted on this form is true and complete. I understand this information is confidential and will be used for statistical and verification purposes. Further, in order to verify my eligibility and in the event that I am accepted to the Success at Southern/ TRIO-Student Support Services (SSS) at Southern Oregon University, I release the following information to the Success at Southern/TRIO-SSS Program:

• Southern Oregon University Academic and Admission/Registration/Financial Aid Documentation
• Southern Oregon University Interdepartmental Consultation
• Midterm and Final Grades Information
• Disability Documentation
• Income Information (Federal 1040 or other appropriate income documentation if required)

Additionally, (1) I allow the SOU TRIO SSS program the ability to lookup my information in the National Student Clearinghouse.
(2) I agree to complete an exit interview in the event of withdrawal, transferring, or graduation from SOU.
(3) I understand that Success at Southern/TRIO-SSS administrators may contact my instructors on an as needed basis.
Student's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
PLEASE CHECK THAT YOU HAVE COMPLETED AND HAVE ANSWERED ALL QUESTIONS. FAILURE TO COMPLETE IT WILL RESULT IN YOUR APPLICATION BEING REJECTED.

IMPORTANT: We like to recognize student achievements. We will include your name or picture for program related publicity, exhibits or displays? If you would like to opt out, please check box, initial.
OPT OUT

By initially below, I am not giving permission to use my name or photo for program related publicity.
I do not give Permission to PRINT NAME
Initial
I do note give Permission to PRINT PHOTO
Initial
NEITHER name or photo
Initial

Student Support Services