Austin Peay State University-SSS-Application Form

TRiO Student Support Services (SSS)

Application Form
TRiO Student Support Services is funded ($318,277) annually by the U.S. Department of Education.

For students to participate in TRiO Student Support Services, one or more of the following requirements must be met, based on the legislative requirements of the U.S. Department of Education:

Family income meets published federal guidelines (low-income)
Neither biological/adoptive parent earned a four-year college degree (first-generation)
Referral by the APSU Disability Office

Additionally, the student must be a U.S. citizen or permanent resident to participate in the program.
The student must demonstrate an academic need for services and have the potential to benefit from the services. It is possible that students will be placed on a waiting list for services, due to limited enrollment.

Please answer all questions to the best of your knowledge.
Responses on the application may not accurately represent current circumstances of situations.
Name:*

First NameMiddle NameLast Name
Preferred Name
Permanent Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
APSU Box:
Use if you live on-campus
APSU E-mail:*
example@example.com
Telephone:*
(999)999-9999
Banner ID (A) Number:*
Other Telephone:
(999)999-9999
Preferred method of contact

EmailTextPhone Call
SSN:*
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Sex:*

Male (1)Female (2)
Ethnic Background: Do you consider yourself to be Hispanic/Latino (4)?*

YesNo
Ethnic Background:*

American Indian/ Alaska Native (1)Asian (2)Black/African American (3)Hispanic/Latino (4)White (5)Hawaiian/Pacific Islander (6)
Eligibility Criteria: Funding is provided by the U.S. Department of Education and requires specific documentation for enrollment into the TRiO Student Support Services Program.
A. Citizenship Status
Are you a U.S. citizen or permanent resident?*

YesNo
B. First-Generation Status
Does your biological/adoptive mother have a 4-year degree?*

YesNo
Does your biological/adoptive father have a 4-year degree?*

YesNo
Who do/did you primarily reside with?
Who do/did you primarily reside with?

MomDadBoth
C. Income Verification
Do your parents claim you as a dependent?*

YesNo
(If yes, then family income is based on parental income and supporting documentation must be provided by the parents). What is your marital status?*

SingleMarried
(If married, then family income is based on you and your spouse and supporting documentation must be provided by both). Did you file federal income taxes in the past calendar year?*

YesNo
To determine income eligibility, please complete the following information below to the best of your knowledge:
Family/Household Size*
Include yourself in the count.
Taxable Income:*
Use Line 15 on the 1040 tax form.
Please click on the link https://www.ed.gov/grants-and-programs/grants-higher-education/federal-trio-programs/federal-trio-programs-current-year-low-income-levels to view the Federal TRIO Programs Current-Year Low-Income Levels.

I certify that the above information is accurate to the best of my knowledge. I understand it may not reflect my current circumstances or situation
(If NO, then please provide income verification from one of the following Government sources:

SS/SSI BenefitsAFDC/ADC from Department of Human ServicesVA BenefitsWorkmen's CompensationProof of Child SupportUnemployment BenefitsOther
I am considered low-income by federal guidelines*

YesNo
D. Disability Status
Are you registered with APSU's Disability Office?*

YesNo
Do you plan to register with APSU's Disability Office?*

YesNo
E. Degree Status*

YesNo
E. Degree Status
Have you previously earned a bachelor's degree?

YesNo
Do you plan to earn a bachelor's degree with APSU?

YesNo
Have you ever attended college?*

YesNo
If yes, where and
From ___

MonthDayYear
mm-dd-yyyy
To ___

MonthDayYear
mm-dd-yyyy
F. Do you plan to earn a Bachelor's Degree from APSU?*

YesNo
F. Financial Aid
Have you applied for financial aid?

YesNo
Have you been offered financial aid?

YesNo
Who can we thank for referring you to SSS?
How did you hear about us?

TextEmailInfo TablingWebsiteSocial MediaOther
Have you applied for financial aid?*

YesNo
Have you been offered financial aid?*

YesNo
TRiO Student Support Services is a federal program, funded by the U.S. Department of Education. Specific income verification documentation for enrollment into the TRiO Student Support Services program. Please attach a copy of your completed and current FAFSA answers. TRiO Student Support Services is required to verify income elgibility for the program.
FAFSA Answers

Cancelof
Financial aid award history

Cancelof
CERTIFICATION STATEMENT

I certify that all information on this application, including supporting financial and family documentation, is true and correct to the best of my knowledge. I give permission to release my grades, financial aid/tax information, and SSN to TRiO SSS. I understand that the above information will be used for statistical purposes in the Annual Performance Report required by the U.S. Department of Education.
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Austin Peay State University (APSU) does not discriminate against students employees, or applicants for admission or employment on the basis of race, color, religion, creed, national origin, sex (including pregnancy), sexual orientation, gender identity/expression, disability, age, status as a protected veteran, genetic information, or any other legally protected class with respect to all employment, programs, and activities sponsored by APSU. https://www.apsu.edu/equity-access/titleix/index/php
Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy

TRiO Student Support Services (SSS)