Fillable 2019-2020 Higher Education Assistance Program (Pokagon Band of Potawatomi Indians)

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2019-2020 Higher Education Assistance Program (Pokagon Band of Potawatomi Indians)

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Pokégnek Bodéwadmik • Pokagon Band of Potawatomi
Department of Education
Box 180 • 58620 Sink Road • Dowagiac, MI 49047 • www.PokagonBand-nsn.gov
(269) 782-0887 • Please email all documents to DOE.HEAP@PokagonBand-nsn.gov>
1
2019-2020 Higher Education Assistance Program
Deadline: Fall Semester Aug. 1
st
Deadline: Spring/Winter Semester Dec 1
st
Deadline: Summer May 1
st
Dear HEAP Applicant,
Congratulations on pursuing your education.
To complete the application process for the Pokagon Band Higher Education Assistance
Program for the academic semester, the following items need to be completed or turned
into the Department of Education.
Forms Completed
1 Complete HEAP Application including signatures
Y/N
2 Completed Direct Deposit Form
Y/N
3 FAFSA – Student Aid Report - https://fafsa.ed.gov/ Y/N
4 Copy of your most recent unofficial transcript (returning
applications), High School diploma or GED certificate (new
applicants)
Y/N
5 Submit an official copy of your semester class schedule Y/N
6 Financial Aid Verification Form (submitted to institution) Y/N
7 I have read the Higher Education Assistance Program Policy Y/N
8 I am applying for Housing Assistance Y/N
9 I have attached my leasing agreement (current agreement not
expired-letter from landlord if changed to a month-to-month)
Y/N
Email Application and documentation to DOE.HEAP@PokagonBand-nsn.gov
Application Signature: _____________________________________Date: ___________
Pokégnek Bodéwadmik • Pokagon Band of Potawatomi
Department of Education
Box 180 • 58620 Sink Road • Dowagiac, MI 49047 • www.PokagonBand-nsn.gov
(269) 782-0887 • Please email all documents to DOE.HEAP@PokagonBand-nsn.gov>
2
2019-2020 Higher Education Assistance Program (HEAP) Application
Basic Student Information
Name: First:_______________Middle:_____________Last:___________________
Address: Street _____________________ City___________State_____ Zip_______
Telephone: _______________Date of Birth:____________ Email: _________________
Tribal ID Number: __________
I am classified as a: (circle one) Freshman Sophomore Junior Senior Graduate
I am pursuing the following: (circle one)
Certificate Associates Bachelors Masters
My field of study or major: __________________
My expected date of graduation: _____________
Other Student Assistance receiving this Academic Year
PhD Vocational
Michigan Tuition Waiver ______ Pell Grant ______ Other _____________
College/University/Vocational School Information
Name of School: _____________________________Circle One: Private Public Tribal
City: __________________State/Zip: __________
I DECLARE THAT THE INFORMATION GIVEN BY ME ON THIS FORM IS TRUE AND
COMPLETE TO THE BEST OF MY KNOWLEDGE.
Application Signature: _____________________________________Date: ___________
Pokégnek Bodéwadmik • Pokagon Band of Potawatomi
Department of Education
Box 180 • 58620 Sink Road • Dowagiac, MI 49047 • www.PokagonBand-nsn.gov
(269) 782-0887 • Please email all documents to DOE.HEAP@PokagonBand-nsn.gov>
3
2019-2020 HEAP Recipient Agreement
I agree to the following items as a condition of receiving the Higher Education Assistance
Program:
1. Must use funds for education-related expenses.
2. Must attend the institution listed on the application.
3. Must submit an unofficial transcript prior to the beginning of each academic
period (i.e. term or semester) to verify grades.
4. Must submit a copy of schedule to verify class schedule.
5. Must maintain current address, telephone number, e-mail address, and other
contact information with the Pokagon Band Enrollment Department
6. Must maintain a minimum grade point average (GPA) of 2.0 or the minimum
standard for the higher education institution for undergraduate study and 3.0 for
graduate study. If the student’s cumulative grade point average drops below the
determined GPA, the student will be placed on academic probation and must
follow the Academic Improvement Plan found in the HEAP policy
7. Withdrawal from School must be pre-approved by the Higher Education
Specialist. Student must notify the Pokagon Band Department of Education
within (5) business days after dropping a class or withdrawing from school
completely. The portion of the Pokagon Higher Education Scholarship received
for the dropped class must be paid back to the Pokagon Band following the HEAP
policy.
8. Must submit a copy of diploma upon graduation.
9. Must submit an application each semester.
10. Must submit all required paperwork for the semester requesting funding before
the following deadlines to be eligible:
Deadline: Fall Semester Aug. 1
st
Deadline: Spring/Winter Semester Dec 1
st
Deadline: Summer May 1
st
I understand that failure to abide by these conditions may jeopardize my future HEAP
funds.
Application Signature: _____________________________________Date: ___________
Pokégnek Bodéwadmik • Pokagon Band of Potawatomi
Department of Education
Box 180 • 58620 Sink Road • Dowagiac, MI 49047 • www.PokagonBand-nsn.gov
(269) 782-0887 • Please email all documents to DOE.HEAP@PokagonBand-nsn.gov>
4
Proxy/Authorized Account Access
Proxy access allows a student to give someone else (usually a parent or guardian) read
only access to designated portions of a student’s records. Proxies or authorized users can
optionally make payments to a student’s account on the student’s behalf.
All HEAP tuition payments will be paid using proxy access. Please provide proxy login
information below or establish the access through your institution using the email address
DoE.HEAP@pokagonband-nsn.gov as the user email.
We are not requesting or requiring full access to your student online portal. The
user name, user email and password that you use to access your classes, records, etc.
is unique to you and should remain private.
Authorized Payment Request Information
Student I.D.#: __________________
Proxy User Name: _________________Proxy Password: ______________
I DECLARE THAT THE INFORMATION GIVEN BY ME ON THIS FORM IS TRUE AND
COMPLETE TO THE BEST OF MY KNOWLEDGE.
Application Signature: _____________________________________Date: ___________
Pokégnek Bodéwadmik • Pokagon Band of Potawatomi
Department of Education
Box 180 • 58620 Sink Road • Dowagiac, MI 49047 • www.PokagonBand-nsn.gov
(269) 782-0887 • Please email all documents to DOE.HEAP@PokagonBand-nsn.gov>
5
Higher Education Assistance Program
Consent to Release Information
Dear Pokagon Scholarship Recipient,
The Family Education Rights and Privacy Act (known as FERPA) Is a federal law that
protects the privacy of student education records. These rights transfer to the student
when he/she reaches the age of 18 or attends a school beyond the high school level.
Now that you are attending college, it is your decision if to allow other people to have
access to your student information. For instance, we often receive telephone calls from
parents asking if a scholarship check was processed, etc.
According to FERPA, we are required to get your written consent to share any
information with anyone other than you. Below is a consent form. Please review it and
decide with whom-if anyone- we may discuss your student file.
As always, contact our office if you have any questions.
CONSENT TO RELEASE INFORMATION
I, (print name) _____________________________________, give permission to the
Pokagon Band Department of Education to release information regarding my Higher
Education Assistance Program file to the following individuals or institutions:
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
4. __________________________________________________________________
Application Signature: _____________________________________Date: ___________
Pokégnek Bodéwadmik • Pokagon Band of Potawatomi
Department of Education
Box 180 • 58620 Sink Road • Dowagiac, MI 49047 • www.PokagonBand-nsn.gov
(269) 782-0887 • Please email all documents to DOE.HEAP@PokagonBand-nsn.gov>
6
Higher Education Assistance Program
Housing
Please complete the information requested below:
Are you applying for Housing this semester? Yes_________ No________
Housing assistance guidelines:
May be used to pay the student’s mortgage, rent or boarding, etc.;
Shall not be used to pay rent, directly or indirectly, to any parent, custodian or
guardian of the student unless the rental unit is wholly self-contained (completely
separate amenities – kitchen, bathroom, etc.) and the parent, custodian or guardian
does not reside at the rental unit; and
May be used to pay rent to a family member other than a parent, custodian or
guardian.
Have you read, and do you acknowledge, the Housing Assistance guidelines listed
above? Yes________ No___________
Address where you will be residing while you are in school.
Apartment Complex/House or Dorm ___________________________________
Street ___________________ City _____________ State ___ Zip _______
If you are full-time student and interested in applying for housing please submit your
rental agreement or dorm contract with this application. The lease agreement or dorm
contact must not be expired, if you are at the same residence but under a month-to-month
please submit a letter from the landlord/apartment complex stating the month-to-month
change to lease.
Application Signature: _____________________________________Date: ___________
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2019-2020 Higher Education Assistance Program (Pokagon Band of Potawatomi Indians)

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Completed 20 July 2020

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