Lone Star College-North Harris-SSS 2-Application Form

Lone Star College North Harris TRIO Student Support Services
Application Checklist Items
- Complete every line item in the application.
- Sign and date the application.
- Ensure that the income verification form is complete and signed.
You will also need to provide:

1. Two Forms of Identification
- State-issued Driver’s License/ID Card
- Permanent Resident Card
- Passport or Passport Card
- Social Security Card
- Birth Certificate
TRIO SSS is a 100% federally funded program under the U.S. Department of Education.
Affirmative Action/EEO College
Identification 1

Cancelof
Identification 2

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Name:

First NameLast Name
Student ID:
Social Security #:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:
(999)999-9999
Home Phone Number:
(999)999-9999
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Age:
Email Address:
example@example.com
Ethnicity:

Other
Multi-ethnic (More than One):
Citizenship:

Other
Gender:
Are you registered with our Disability Services Office?
Did Parent 1 graduate from college with a 4-year degree?
Did Parent 2 graduate from college with a 4-year degree?
Are you receiving financial aid?
If yes, are you considered an:
If No, check the reason(s):

Other
Current Classification:
Current Course Load:
Disability Services Verification:

Section 12102 of the Americans with Disabilities Act (42 U.S.C. 12101 et seq.), defines a person who has a disability as, “… a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment.”

I certify that I am an individual with a disability as defined above.
Student Signature
When was your first semester at LSC-North Harris?
Month:
Year:
Number Of Course Hours Completed At LSC So Far:
Cumulative GPA:
If you don't know, please type "Don't Know"
What Are Your Current Educational Plans?
I certify that all the information on this form is true and complete to the best of my knowledge. I also authorize the LSC North Harris SSS Project permission to obtain and review any academic and financial documents needed to complete the application process.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
NEEDS ASSESSMENT
What is your educational and career goal?
If undecided, please type "Undecided"

Please indicate the subject(s) that you may need tutoring in?

Rows	Subjects
a)
b)
c)

What days are you available to attend tutoring sessions (check all that apply)?
Did you successfully test into college level math?
Did you successfully test into college level English?
Are you currently employed?
If so, how many hours are you working per week?
What can TRIO Student Support Services do to help you succeed? (Check all that apply):
What obstacles do you feel would prevent you from successfully completing your goals?
Who or what campus service referred you to our program?
Application completion checklist:
Income Verification Form
Name

First NameLast Name

Household Size Information:

Rows	Full Name	Relationship
1
2
3
4
5
6
7
8
9
10

Taxable Income:
Income Verification Requirements
Please provide one of the following items to verify income:
1. Income Verification: Pay stubs, W-2 forms, or a tax return (Form 1040) showing income from the last 30 days to the previous year.
2. Benefit Letters: Official letters from the Social Security Administration (SSA) or Texas Workforce Commission.
3. Public Assistance Records: Documents showing enrollment in SNAP (food stamps) or Medicaid, such as form TF0001.
4. Agency Letters: A letter from a recognized social services agency or hospital district verifying income status.

If you are unable to provide any of the items listed above, complete the applicable certification below.

A. Dependent Student: I verify that the taxable income provided is true and complete to the best of my knowledge.
Parent Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
B. Independent Student: I verify that the taxable income provided is true and complete to the best of my knowledge.
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File Upload

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Income Verification Requirements

Please provide one of the following documents to verify income:
1. Income Verification: Pay stubs, W-2 forms, or a tax return (Form 1040) showing income from the last 30 days to the previous year.
2. Benefit Letters: Official letters from the Social Security Administration (SSA) or Texas Workforce Commission.
3. Public Assistance Records: Documents showing enrollment in SNAP (food stamps) or Medicaid, such as form TF0001.
4. Agency Letters: A letter from a recognized social services agency or hospital district verifying income status.
You can find this number on your parent’s most recent Tax Return. If you are considered an Independent Student, this will be on your own Tax Return

-For your 2024 Tax Return you can find “Taxable Income” on your 1040 Tax Return.
Student Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Parents Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
(Parent signature needed If you are considered a Dependent student. If you filed a FAFSA, check your status to determine if you are considered a Dependent or Independent student)

(We certify that this statement is true and correct to the best of our knowledge.)

Lone Star College North Harris TRIO Student Support Services