Utah Valley University-SSS-Application Form

2024-2025 TRIO SSS Application
Reminder: TRIO SSS serves First-Generation, Low-income, and/or students with a disability; and are currently enrolled & seeking to earn a Bachelor’s Degree from UVU.
*If you have any questions about your eligibility, please reach out to Frenely Liechty (frenelyl@uvu.edu)

General Information
Full Name:*

First NameMiddle InitialLast Name
Local Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
(999)999-9999
University Student Email Address:*
StudentID#@uvu.edu
UVU ID:*
Date of Birth: *

MonthDayYear
mm-dd-yyyy

Eligibility Information
Have you completed your FAFSA for the 2024-2025 academic year?*

YesNo
Did you receive the TRIO SSS Scholarship for 2023-2024?*

YesNo

Low-Income Verification Eligibility
Independent Student: An independent student is one of the following: at least 24 years old, married, graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.

Dependent Student: A dependent student is under 24 years old and does not fit under any of the categories listed under independent student above. As such, in order to qualify for our program under low-income eligibility, the student must have a recent and complete FAFSA on file at UVU confirming the dependent student’s income status. The dependent student’s parent or legal guardian will have had to sign their FAFSA Submission.
Based on the above definitions, I certify that I am:*

An Independent StudentA Dependent Student
An Independent Student (initial)*
A Dependent Student (initial)*

Determining Low-Income Eligibility:

(Effective January 11, 2024 until further notice)

Size of Family Unit	48 Contiguous States, D.C., and Outlying Jurisdictions	Alaska	Hawaii
1	$22,590	$28,215	$25,965
2	$30,660	$38,310	$35,250
3	$38,730	$48,405	$44,535
4	$46,800	$58,500	$53,820
5	$54,870	$68,595	$63,105
6	$62,940	$78,690	$72,390
7	$71,010	$88,785	$81,675
8	$79,080	$98,880	$90,960

For family units with more than eight members, add the following amount for each additional family member: $8,070 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $10,095 for Alaska; and $9,285 for Hawaii.

The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

The figures shown under family income represent amounts equal to 150 percent of the family income levels established by the Census Bureau for determining poverty status. The poverty guidelines were published by the U.S. Department of Health and Human Services in the Federal Register on January 17, 2024 and are effective as of January 11, 2024.

Certification*

As an Independent: I certify that I have read and understand the chart above and as such have determined that I am a low-income student.As a Dependent: My FAFSA is up to date and on file with UVU's Financial Aid Department. I also understand that if this information is not correct according to UVU, TRIO may ask me to perform further necessary actions.N/A
Student signature*

Clear

Disability Verification Eligibility
Are you am applying to TRIO Student Support Services as a UVU Accessibility Program Participant?*

YesNo

First Generation Verification Eligibility
Mother’s Information
Mother’s Name:*

First NameLast Name
Did your mother receive a Bachelor’s Degree?*

YesNo
Father’s Information
Father’s Name:*

First NameLast Name
Did your father receive a Bachelor’s Degree?*

YesNo

Release of Information
Release of Information/ Permissions

I authorize:
- TRIO Student Support Services to gather information concerning my academic progress (standardized test scores, grade point average, earned credits, transcripts) and financial aid status prior to my participation in SSS.
- I understand that this information is used to assist in the determination of my
  eligibility for SSS, and it will be strictly confidential.
- I grant permission for TRIO SSS to gather information for follow-up whenever appropriate, including transfer and progress at 4-year institutions, I am aware that my eligibility and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations.
- I authorize and direct Utah Valley University to verify my family's income using Federal Tax Information (FTI) and/or Adjusted Gross Income (AG) from my FAFSA account for the purpose of verifying my eligibility to participate in the TRIO programs.
- I agree that this verification may be provided to the TRIO programs at Utah Valley University for the specific purpose of participation in the TRIO programs.
- I understand there are other ways to provide verification of financial need and have chosen this option of my own free will and choice.
- I certify that the information provided on the application is true and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information reported.
- I am also aware that the personal information that is provided to the TRIO Student Support Services program will be protected under the Family Education Rights and Privacy Act if 1974. No one will have access to the information unless they work with or for the TRIO SSS program/Utah Valley University, or are specifically authorized by the student in question to see the information.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Permission for photo/video of me at TRIO events for promotional/educational purposes:
- I understand that if I’m accepted into the program and attend services/events,
  photographs and/or video or audio recordings may be taken of my voice or image for educational or promotional purposes. I hereby grant to TRIO Student Support Services (at UVU) a non-exclusive license and right to use excerpts or completed works that may contain either an audio or video representation of myself. I agree and understand that TRIO may retain full ownership and usage rights of any photographs taken of me (including digital, transparency, print and/or negative format) in still, single, multiple, moving or video format.
Permission for photo/video of me at TRIO events for promotional/educational purposes:*

Yes, I give permission to TRIO to use photos of me at TRIO events/spaces for promotional/educational purposes.No, I would prefer TRIO does not use any photo/video/audio of me for TRIO Purposes.
Initial*

2024-2025 TRIO SSS Application