California Polytechnic State University-SLO-SSS-2025 Application Form 2

California Polytechnic State University-SLO-SSS
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Personal Information
First and last name*

First NameLast Name
Nickname or preferred name
Preferred Pronouns
Cal Poly email address *
example@example.com
Cal Poly EMPL/Student ID Number*
Phone number*
(999)999-9999
I am a*

First-year college student- I have completed high schoolTransfer student from a previous college institutionContinuing Cal Poly student

Income Verification
Federal Regulations require the TRIO/SSS Program at AHC to obtain household and income information to determine eligibility for each student applying to participate.

Please check yes or no*

	Yes	No
As of today, are you married? (Answer “No” if you are separated but not divorced.)
At the beginning of the 2025–26 school year, will you be working on a master’s or doctorate program (such as an M.A., MBA, M.D., J.D., Ph.D., Ed.D., graduate certificate, etc.)?
Are you currently serving on active duty in the U.S. armed forces for purposes other than training? (If you are a National Guard or Reserves enlistee, are you on active duty for other than state or training purposes?)
Are you a veteran of the U.S. armed forces?*
Do you have children or other people (excluding your spouse) who live with you and who receive more than half of their support from you now and between July 1, 2025, and June 30, 2026?
At any time since you turned age 13, were you an orphan (no living biological or adoptive parent)?
At any time since you turned age 13, were you a ward of the court?
At any time since you turned age 13, were you in foster care?
Are you or were you a legally emancipated minor, as determined by a court in your state of residence?
Are you or were you in a legal guardianship with someone other than your parent or stepparent, as determined by a court in your state of residence?
At any time on or after July 1, 2024, were you unaccompanied and either (1) homeless or (2) self-supporting and at risk of being homeless?**

How do I know if I am an independent or dependent student? https://studentaid.gov/apply-for-aid/fafsa/filling-out/dependency

** Not living with parents or not being claimed by them on tax forms does not make you an independent student for purposes of applying for federal student aid.**
For financial purposes, are you considered a dependent or independent student*

DependentIndependent
If you are considered an INDEPENDENT student for financial aid reasons, you must provide YOUR information and taxable income below. If you are considered a DEPENDENT student for financial aid reasons, you must provide the information and taxable income of your natural or adoptive parents below.

If you or your parents did not complete an income tax form, record the total of untaxed income for the household during the previous yea
Number in your household (including yourself)*

12345678Other
Please indicate total family annual TAXABLE INCOME from 2024: Taxable Income is the total AFTER your deductions are taken. This can be found in IRS form 1040 - line 15 or 1040-SR – line 11b.*

Personal Statement and Signature
In less than 500 words, include any information you feel will assist us in learning as much about you, your interest, and your need for the services provided by TRIO Achievers. Your autobiography may include: your birthplace, where you grew up, why you want to participate in TRIO Achievers, how TRIO Achievers can assist you, which services you can benefit from, academic achievements, academic struggles and your goals in life.*
EQUAL OPPORTUNITY

Thank you for your interest in the TRIO Achievers/Student Support Services at Cal Poly. All applicants will be considered without regard to race, color, religion, national origin, sexual orientation, marital status or disability.

DECLARATION

I understand that as a participant in TRIO Achievers (also known as Student Support Services), any or all of the academic support services of Student Affairs will be available to me. I understand that all data collected will be kept confidential. By typing and signing my full legal name in the box and clicking submit, I grant permission to TRIO Achievers to track all of my academic progress at Cal Poly and at any other academic institution. I authorize the release of my student academic, personal and financial aid records for the TRIO Achievers program to use and for reporting purposes to the U.S.

Department of Education. In addition, I hereby give my permission for my photograph, work and/or statements to be used by TRIO Achievers for promotional, publicity or instructional purposes. All information provided is accurate to the best of my knowledge.
Full legal name of applicant*

First NameLast Name
Digital signature of applicant*

Clear
*Note if you are dependent on your parent’s income, they must sign this application before submission to confirm the tax information listed is accurate.
Full legal name of parent/guardian (if you are a dependent student

First NameLast Name
Digital signature of parent/guardian (if you are a dependent student

Clear
Date*

MonthDayYear
Date