Austin Peay State University-SSS-Application Form

TRiO Student Support Services (SSS)

Application Form
How to Apply

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 parent earned a four-year college degree (first generation, and
- Referral by the Student Disability Resource Center (disabled).
Additionally, 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.
Name:*

First NameMiddle NameLast Name
Preferred Name
Permanent Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
APSU Box:
APSU E-mail:*
example@example.com
Telephone:*
(999)999-9999
Banner ID (A) Number:*
Other Telephone:
(999)999-9999
SSN:*
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Gender:*

Male (1)Female (2)Non-binary (3)
Ethnic Background: Do you consider yourself to be Hispanic/Latino (4)?*

YesNo
In addition, select one racial category that applies:*

American Indian/ Alaska Native (1)Asian (2)Black/African American (3)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 (parent s or guardian s educational level)
Mother has a 4-year college degree.*

YesNo
Father has a 4-year college degree.*

YesNo
C. Income Status:
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
(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 the Student Disability Resource Center?*

YesNo
Do you plan to register with the Student Disability Resource Center?*

YesNo
E. Have you previously earned a Bachelor's Degree?*

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
Have you applied for financial aid?*

YesNo
Have you been offered financial aid?*

YesNo
Please attach a copy of your financial aid award history. TRiO Student Support Services is required to verify through Student Financial Aid Office (SFAO) the amount of financial aid needed, the amount of financial aid offered, the amount of unmet need, the amount of grant aid offered, and the reason full financial aid not awarded.
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. In addition, I give permission to release my name and/or picture to provide recognition in newsletters, web pages and/or other pub lications. By signing this application, I understand that this will be an active contract, as long as I meet the requirements for the program. An email will be sent with the covered contract of what services are expected from both parties.

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 affirms that it does not discriminate based on race, color, religion, national origin, sex, sexual orientation, age, disability or veteran status in the educational programs or activities which it operates, or in admission to or employment in such programs or activities, as set forth in Title VI and VII, Title IX, section 504, and ADA. Also see University Affirmative Action Philosophy in Student Handbook and Planner.

Financial Aid Consent

I give permission to TRiO Student Support Services of Austin Peay State University to work with the Student Financial Aid Office of Austin Peay State University to secure the necessary data, if needed, to complete my TRiO Student Support Services application.
Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy

TRiO Student Support Services (SSS)