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19 Fallapp 1 (Johnston Community College)

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BROWSE JOHNSTON COMMUNITY COLLEGE FORMS

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Golden LEAF Scholars Program
Potential candidates must meet the following guidelines:
Resident of a NC county listed on Attachment I
Meet the Federal TRIO Program requirement listed on
Attachment II
Provide a SIGNED 2018 Federal Tax Return
***If you did not work during 2018, please complete a Non-Employment
Attestation form (see attached checklist).
***If you worked during 2018, but did not file taxes, please complete a Student
Non-Tax Filer Attestation form (see attached checklist) and submit a copy of your
2018 W-2s.
Provide completed Golden LEAF application and all
attached waivers
Provide a working email address for correspondence
Maximum reimbursement award amount is
$250.00
Deadline for application:
Friday, November 8, 2019 at 12:00 pm
Application must be submitted to:
Workforce Development Center
135 Best Wood Drive, Clayton, NC
OR
JCC Front Desk Receptionist, Wilson Building, Main Campus
North Carolina Community Colleges
Golden LEAF Scholars Program – Two-Year Colleges
Student Application
Instructions: Complete this application and return the completed application to the college’s Financial Aid Office.
Occupational Education students must also submit a copy of their transcript with the application.
Personal Information:
Full Name: _________________________________________________________________________
Social Security Number: _______________________________________________________________
Home Address: ______________________________________________________________________
City, State, Zip Code: __________________________________________________________________
E-Mail Address: ______________________________________________________________________
Phone Number: _____________________ Mobile number: ____________________
NC County of residence: _______________________________________________________________
Length of residence in county: less than 5 years 5–10 years 10+ years
(To be eligible for this scholarship, your permanent residence must be in an approved NC county.)
Educational Information:
College you are attending: _____________________________________________________________
Occupational Continuing Education Student (must be enrolled in a credentialing program of at least
96 hours.)
Program you are enrolled in: _______________________________________________________
Curriculum Student: GPA 1
st
semester not enrolled
Program you are enrolled in: _____________________________________________________
Other Information:
Have members of your immediate family worked for or owned a farming or agricultural related business now or in
the past? Yes No
Have you or members of your immediate family been employed in traditional industries such as furniture, textiles,
or tobacco manufacturing? Yes No
Has anyone in your household lost their job in the past two years? Yes No
Has anyone in your household transitioned from a full-time job to a part-time job? Yes No
Please list all campus and community service activities you are currently involved in.
Use of Funds:
____ Tuition ____ Fees ____ Books ____ Supplies ____ Mid-Skills Credentialing Exams
____ *Childcare _____ *Transportation
(* Students using funds for childcare and/or transportation purposes are asked to sign the statement(s) below.)
I have read and understand the requirements for assistance. I hereby declare that the information provided on this form
is complete and correct to the best of my knowledge.
_______________________________________ ____________
Applicant’s Signature Date
Please return the completed application to the college’s Financial Aid Office.
Use of childcare funds statement: If selected for funding from the Golden LEAF Scholars Program – Two-Year
Colleges, I certify that scholarship funds designated for childcare will be used exclusively while I am attending
class in order to fulfill my educational requirements.
_______________________________________ ____________
Applicant’s Signature Date
Use of transportation funds statement: If selected for funding from the Golden LEAF Scholars Program –
Two-Year Colleges, I certify that scholarship funds designated for transportation will be used exclusively for the
purpose of supporting my travel to and from the college where I am enrolled for educational purposes.
_______________________________________ ____________
Applicant’s Signature Date
College Media Consent Agreement
Golden LEAF Scholars Program – 2 year Colleges
(This form is for college media release and should be filed at the college. Please do not send this form to the
NCCC System Office.)
The Federal Family Education Rights and Privacy Act of 1974 (FERPA) prohibits colleges and universities from
providing certain information from student records to third parties. FERPA is a Federal law that protects the
privacy of student education records. In general, in order for your college or university to release information
protected by FERPA to anyone, other than yourself, you must approve the release.
I have read and understand the requirements for the Golden LEAF Scholars Program – 2 Year Colleges.
I understand and agree that if I am selected as a scholarship recipient for the Golden LEAF Scholars Program – 2
Year Colleges, the college can share my name and contact information and information regarding my use of
Golden LEAF scholarship funds and my program of study with Golden LEAF for its purposes including monitoring,
assessment, implementation, and administration of the scholarship program.
______________________________ _______________
Applicant’s signature Date
______________________________ _______________
Parent or Guardian’s Signature Date
(If applicant is under 18)
Media Release
You must check one of the following options below:
I approve the release of my information (name, town, program of study) for a media release announcing
my Golden LEAF scholarship
I do NOT approve the release of my information (name, town, program of study) for a media release
announcing my Golden LEAF scholarship
______________________________ _______________
Applicant’s signature Date
______________________________ _______________
Parent or Guardian’s Signature Date
(If applicant is under 18)
Golden LEAF Scholars Program – Two-Year Colleges
Social Security Number Waiver Form
College: _JOHNSTON COMMUNITY COLLEGE_
Student Name: _________________________________________________________
The Golden LEAF Foundation requires every student receiving funds from the Golden LEAF Scholars Program –
Two-Year Colleges, be tracked for graduation and employment status. This necessitates submission of a
student’s social security number and physical address which will be used only for this purpose. The Family
Education Rights and Privacy Act (FERPA) and state law (Session Law 2005-414) require permission to be given
for social security numbers to be used for this purpose.
Please check the statement that applies.
I hereby give my permission for my social security number, address, and e-mail address to be used for
tracking purposes only in relation to the Golden LEAF Scholars Program – Two-Year Colleges.
I do NOT give permission for my social security number nor addresses to be used for any purpose
relating to the Golden LEAF Scholars Program – Two-Year Colleges. By checking this option, you will not
be eligible for an award.
_____________________________________ ___________________
Student Signature Date
_____________________________________ ___________________
Financial Aid Officer Date
Financial Aid Officer: Student addresses will be added to the student roster/spreadsheet. However, the student’s
social security number must be listed at the bottom of this form; do NOT include the social security number on
the student roster.
Please this waiver for each selected recipient to:
NCCCS, Melissa R. Lentz, 5016 Mail Service Center, Raleigh, NC 27699-5016
Student Information
*** Please provide ALL nine digits of your social security number. ***
Student’s Social Security Number: __________--__________--_________
___________________________________________ ___________________
Student’s Signature Date
___________________________________________
Student’s PRINTED Name
Number of Household Members
Student Name: __________________________________________________________
List below the people in the student’s household. Include:
• The student
• The student’s spouse, if the student is married.
• The student’s or spouse’s children, if the student or spouse provide more than half of the
children’s support and will continue to provide more than half the support through June 30,
2017.
• Other people if they now live with the student and the student or spouse provides more than
half of the other person’s support, and will continue to provide more than half of that person’s
support through June 30, 2017.
Full Name
Age
Relationship
Johnston Community College
Continuing Education Golden LEAF Reimbursement Checklist
(with Non-Tax Filer Attestation & Student Non-Employment Attestation Form)
Student Name: _________________________________________________
The following have been provided (check all that apply):
Completed application
All waivers
Number in Household Form
Copy of signed 2017 tax return (W-2s alone are NOT acceptable)
OR
Signed “Non-Tax Filer Attestation” with 2017 W-2s or “Student Non-Employment Attestation”
I affirm I have completed, in full, all criteria required for this application. And, all information provided
is true and accurate to the best of my knowledge.
Student signature: _________________________________ Date: _______________
Non-Tax Filer Attestation
I, _________________________________, affirm I did not file taxes for 2017.
(print first & last name)
Student signature: _________________________________ Date: _______________
Student Non-Employment Attestation
I, _________________________________, affirm I was NOT employed during the 2017 tax year and
(print first & last name)
did NOT receive any government assistance (ex. SAP, TANF, WIC, disability, etc).
Student signature: _________________________________ Date: _______________
Attachment I
Golden LEAF Scholars Program – Two Year Program
Qualifying Counties 2018-2019
Alamance
Granville
Person
Alexander
Greene
Pitt
Alleghany
Halifax
Randolph
Anson
Harnett
Richmond
Ashe
Haywood
Robeson
Avery
Hertford
Rockingham
Beaufort
Hoke
Rowan
Bertie
Hyde
Rutherford
Bladen
Jackson
Sampson
Burke
Johnston
Scotland
Caldwell
Jones
Stanly
Camden
Lee
Stokes
Caswell
Lenoir
Surry
Catawba
Lincoln
Swain
Cherokee
Macon
Transylvania
Chowan
Madison
Tyrell
Clay
Martin
Vance
Cleveland
McDowell
Warren
Columbus
Mitchell
Washington
Craven
Montgomery
Wayne
Davidson
Nash
Wilkes
Davie
Northampton
Wilson
Duplin
Onslow
Yadkin
Edgecombe
Onslow
Yancey
Franklin
Pasquotank
Gates
Pender
Graham
Perquimans
Scholarships are limited to students who demonstrate financial need and reside in a rural county that is
economically distressed and/or tobacco dependent. A scholarship recipient who resides in an eligible county upon
initial award will retain eligibility and will be eligible for renewal awards as long as the student’s place of residence
is within the state of North Carolina and the other scholarship eligibility criteria are met.
Attachment II
Federal TRIO Programs
Current-Year Low-Income Levels
2017 Federal Poverty Guidelines
Federally facilitated marketplaces will use the 2016 guidelines to determine eligibility
for Medicaid and CHIP.
Household
Size
100% 133% 150% 200% 250% 300% 400%
1
$12,060
$16,040
$18,090
$24,120
$30,150
$36,180
$48,240
2
16,240
21,599
24,360
32,480
40,600
48,720
64,960
3
20,420
27,159
30,630
40,840
51,050
61,260
81,680
4
24,600
32,718
36,900
49,200
61,500
73,800
98,400
5
28,780
38,277
43,170
57,560
71,950
86,340
115,120
6
32,960
43,837
49,440
65,920
82,400
98,880
131,840
7
37,140
49,396
55,710
74,280
92,850
111,420
148,560
8
41,320
54,956
61,980
82,640
103,300
123,960
165,280
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Completed 27 July 2020

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