California State University-Dominguez Hills-SSS-Application Form

Application for Program Services
What is Student Support Services Program?
Student Support Services Program is a federal funded program designed to provide academic assistance and enhance educational opportunities for SSS Participants. Our program is designed to support the academic needs of 160 eligible CSU, Dominguez Hills students. Participants are offered a variety of services to ensure a smooth transition to CSUDH as well as ongoing support towards the successful completion of their postsecondary education.

This program and its services is offered free of charge to participants.

Eligibility is based on federal funded criteria:
• Students who meet low-income qualifications
• Students whose parents or guardian have not earned a bachelor’s degree
• Individuals who have a disability

SSS participants must be:
• Admitted and enrolled at CSU, Dominguez Hills
• Pursuing a first bachelor’s degree
• Demonstrate or self-report academic needs
• Committed to utilizing academic support to earn a bachelor’s degree

SSS Application Packet Checklist:
1. SSS Application
2. Unofficial Transcripts from previous schools attended
3. Copy of your ID (state or school)
4. Income Verification document/statement

SSS Office Location
Student Support Services Program
1000 E. Victoria St.
East Academic Complex (EAC) 300
Carson, CA 90747

Phone: 310-243-2143
Email: sss@csudh.edu
Website: http://www.csudh.edu/sss/

How can SSS help you?
• Individualized counseling & advising
• Academic and personal support
• Computer lab and printing access
• Tutoring services
• Graduate school assistance
• Financial literacy education
• Priority registration
• Cultural field trips
• Student leadership conference opportunities

Please read and complete all sections on the application. Incomplete applications will delay processing.

FINANCIAL INFORMATION
Please confirm if you are independent or dependent student*

IF YOU ARE AT LEAST 24 YEARS OLD OR IF YOU ARE CONSIDERED TO BE AN "INDEPENDENT” STUDENT ON THE FAFSA, YOU MUST ANSWER THE FOLLOWING QUESTIONS ABOUT YOURSELF.IF YOU ARE 24 YEARS OLD OR YOUNGER AND YOU ARE CONSIDERED TO BE A “DEPENDENT” STUDENT ON THE FAFSA YOUR PARENT / GUARDIAN MUST ANSWER THE FOLLOWING QUESTIONS AND SIGN THIS DOCUMENT TO VERIFY.
Have you completed the FAFSA for this academic year?*

YesNo

Independent
Provide the total number of persons in your household, including yourself*
Select ONE and complete the required information*

Yes, I filed a federal income tax last yearNo, I did NOT file federal income tax last yearNo, I did not have taxable income last year
Provide the STATE you filed taxes in*
Provide your TAXABLE INCOME amount*
Provide your TOTAL INCOME last year*
(If YOU did not file your income tax: submit a statement stating that you did not file income taxes form must be signed)
Upload Income Tax form (must include Taxable Income, usually found in the first two pages) OR Income Tax Statement (Forms must be signed)*

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Additional Documents

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Dependent
Provide the total number of persons in your PARENTS/GUARDIANS household, including yourself*
Select ONE and complete the required information*

Yes, my PARENTS/GUARDIANS filed a federal income tax last yearNo, my PARENTS/GUARDIANS DID NOT file federal income tax last yearNo, my PARENTS/GUARDIANS did not have taxable income last year
Provide the STATE they filed taxes in*
Provide their TAXABLE INCOME amount*
Provide THEIR TOTAL INCOME last year*
(If your PARENTS/GUARDIAN did not file income tax: submit a statement stating that they did not file income taxes form must be signed)
Upload Income Tax form (must include Taxable Income, usually found in the first two pages) OR Income Tax Statement (Forms must be signed)*

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Additional Documents

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INFORMATION & AUDIO/VISUAL RELEASE
Submitting this application enables California State University, Dominguez Hills (CSUDH) TRIO Student Support Services to obtain necessary academic and personal information and records, including grade reports and transcripts, admission, enrollment, financial aid eligibility and awards, U.S. residency status demographic and contact information, for the purpose of determining eligibility, developing education plans & recording, and collecting program statistics. I authorize the CSUDH TRIO Student Support Services touse information and photographs related to my program participation and newsletters, CSUDH, TRIO, WESTOP webpages & social media releases and other program-related publications. This information may be shared with the U.S. Department of Education, California State University, Dominguez Hills and TRIO personnel in accordance with federal regulations and CSUDH university policies.

I/We certify that all of the information contained within this application is complete and correct to the best of my knowledge.
Student signature:*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian’s signature:

Clear
(Parent /Guardian signature is required if student is under the age of 24 and is considered a DEPENDANT student)
Date

MonthDayYear
mm-dd-yyyy
Statement of Confidentiality: The information contained in this application is for the purpose of determining the applicant’s eligibility for the Student Support Services Program. All information received is confidential.

Revised June 2022

TRIO Student Support Services at CSUDH is 100% federal funded.

Application for Program Services