Passaic County Community College-SSS-Application Form

PASSAIC COUNTY COMMUNITY COLLEGE

Student Support Service Classic Program Application
TRiO Student Support Services (SSS) Classic is a federally funded program providing academic and financial support to eligible PCCC students who meet at least one federal criterion: first-generation college student, federal low-income guidelines, or documented disability registered through the Office of Accessibility Services (OAS) and demonstrate a need for academic support to successfully pursue a postsecondary education. To be considered, students must:
1. Have placed into Developmental English (DE 20), Developmental Math (MA 025), or above.
2. Be enrolled in, or plan to enroll in, an A.A. or A.S. transfer degree or certificate program at PCCC.
3. Demonstrate a need for academic support, as determined through the application and intake process.
- Name:
  
  First NameLast Name
- PCCC ID:
- DOB:
  
  MonthDayYear
  mm-dd-yyyy
- Gender:
  
  Other
- Home Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- County:
- Cell Phone:
  (999)999-9999
- Home Phone:
  (999)999-9999
- PCCC Email:
  example@students.pccc.edu
- Other Email:
  example@example.com
- Please attach a copy of your ID
  
  Cancelof
- Ethnicity:
- Ethnic/Racial Background:
- The information requested on race, ethnicity and sex is not used in the selection process. It is set aside and used in reports to the Department of Education in Washington D.C. It is the policy of the Student Support Services program not to discriminate on the basis of sex, race, religion, color, national origin, age and disability in its decisions
- Do you have a documented disability?
- Are You a U.S. Citizen?
- Are you a Permanent Resident of the United States?
- Have you completed an Associates or Bachelor’s degree from any college or university?
- Did either of your parents/guardians with whom you reside Graduate from a College with a 4-Year Bachelor’s Degree?
- Programs you have participated in (indicate all that apply):
- Where?
- Are you a Transfer Student?
- If yes: Name of Institution
- Current or Intended Major of Study:
- What is your educational goal at PCCC?
- To provide income information, choose the option that applies to you.
- Option 1
- Number in Household
- Family's Taxable Income
- Student's Taxable Income
- Upload tax information
  
  Cancelof
- Option 2
- In accordance with the TRIO SSS Classic eligibility requirements set forth by the United States Department of Education, I hereby certify that NO Federal or State tax return documenting my income or my parent’s/guardians was filed with the Internal Revenue Service for the previous tax year of
- Complete one (1) that applies:
- I CERTIFY THAT I am a dependent student and my parent’s/guardian’s TOTAL INCOME from all sources in the year of
- I CERTIFY THAT I am an independent student and my TOTAL INCOME from all sources in the year of
- Optional: if income is exceptionally low, please explain on the bottom of this page how you or your family was supported on this income.
- By signing this document, I/WE attest under penalty of perjury that the above statement is true and correct.
- Student Signature
  
  Clear
- Parent Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- If you are a dependent student, please use your parent/guardian's most recent income tax information and your own income information (if applicable). I am including my/my parents’ income information.
- If you are an independent student, please provide your own income tax information. I am including my income tax information.
- I am including my signed FAFSA Student Aid Report (SAR).
- If you or your family did not file an income tax return last year, please indicate a need to complete the Program’s Dependent/Independent Income Verification form provided by our office. I am requesting a Verification Form.
- Number in Household:
- Family's Taxable Income*:
  $
- Student's Taxable Income*:
  $
- My family did not file income taxes:
- *Please submit pages 1 and 2 of your Family's most recent Income Tax Return, showing Taxable Income (Form 1040, line 15).
  
  Cancelof
- Student Name:
  
  First NameLast Name
- ID:
- In accordance with the TRIO SSS Classic eligibility requirements set forth by the United States Department of Education, I hereby certify that NO Federal or State tax return documenting my income or my parent’s/guardian’s was filed with the Internal Revenue Service for the previous tax year of __________.
- Complete one (1) that applies:
- I CERTIFY THAT I am a dependent student and my parent’s/guardian’s TOTAL INCOME from all sources in the year of _________
- was $___________________.
- I CERTIFY THAT I am an independent student and my TOTAL INCOME from all sources in the year of _____________
- was $ _____________________.
- (Note: if income is exceptionally low, please explain on the bottom of this page how you or your family was supported on this income.)
- Total number of exemptions in household:
  (Include parent(s), yourself, and other dependents)
- By signing this document, I/WE attest under penalty of perjury that the above statement is true and correct.
- Student’s signature:
  
  Clear
- Date
  
  MonthDayYear
  Date
- Parent’s/guardian’s signature:
  
  Clear
- Date
  
  MonthDayYear
  Date
- What types of services would help you successfully reach your academic goals? (Indicate all that apply):
- I give Passaic County Community College and the TRiO Student Support Services Program, permission to record the image and/or voice of myself as named. I grant Passaic County Community College all rights to use sound, still, or moving images in any medium for educational, promotional, advertising, or other purposes that support the mission of the college.
- Please select:
- Initials
- If selected, upon my acceptance to the TRiO Student Support Services program, I agree to fulfill all my requirements as a program Scholar and be committed to my academic and personal achievements at Passaic County Community College. I also agree to the following:
  - I will meet with my TRiO Student Support Services Counselor, one time each month during the fall and spring semester throughout my academic career at PCCC to review my progress.
  - I agree to participate in workshops and activities provided by Student Support Services and will attend at least two (2) workshops during each semester.
  - I must attend tutoring sessions during the semester in the SSS Learning Center (A-223), if referred by my counselor.
  - I agree to register and maintain at least 9 and successfully complete a minimum of 24 credits each academic year.
  - I accept the responsibility for acquainting myself with registration, withdrawal, and refund policies and procedures set forth in the current PCCC Catalog and Schedule.
  - I agree to attend and participate in the SSS Classic Summer Enrichment
- Please select:
- Initials
- I, hereby certify that all answers and information provided, constitute a full and complete disclosure with respect to this application. I understand that this application is being made in connection with the receipt of federal funds, and the U.S. Federal Government and the U.S. Department of Education may verify this information.
- Student Signature:
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Parent/Guardian Signature:
  
  Clear
- (If providing parent’s Income Tax, please have them sign above)
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- I authorize use of my name and photograph to be published in Student Support Services' publications. I also certify that all of the above information is correct. Completion of the application does not guarantee acceptance into the program.
- STUDENT SUPPORT SERVICES -
  
  Passaic County Community College
  
  Founders Hall, Room E204
  
  One College Boulevard, Paterson, NJ 07505
  
  Office Phone: 973-684-7170
  
  Email: sss@pccc.edu

PASSAIC COUNTY COMMUNITY COLLEGE

Option 1

Option 2