PART III: Family Information
Please answer the following questions about your parents and yourself:
Has your mother received a Bachelor’s Degree? _____yes ______no
Has your father received a Bachelor’s Degree? ______yes ______no
A. Check all that apply to you (the student) _______Over 24 years of age ________Armed Forces Veteran
______Ward of the state _____Provided dependency override by DSLCC financial aid office ____Both parents deceased
If you have dependent children (answer all that apply): How many children? _______ Are you a single parent? _______
Do you receive TANF? ______
If you checked any of the options above in part A, go to part C. If you did not, continue to part B.
B. Please indicate how many people are part of your household: Self ______Mother ______Father ______
Number of brothers and sisters _____ (you may count them if they are in college and your parents support them, even if
they do not live at home). Number of other dependents claimed on tax return__________
C. Total in household______
Part IV: Finances
Did you apply for (FAFSA) student financial aid? _________ Did you receive aid? _________
*What is your family’s taxable income (not total) from last year?
(Please check one and provide information)
_____ My family’s taxable income (not total) was $____________________
_____ My family did not file a federal income tax return for the last calendar year. My family’s total
income from the last calendar year was $_______________________
_____ My family had no taxable income during the last calendar year.
*Taxable income can be found on the federal income tax return: On IRS Form 1040, see line 43.
On IRS Form 1040A, see line 27. On IRS Form 1040 EZ, see line 6.
I authorize the Student Support Services staff at Dabney S Lancaster Community College to
obtain academic, financial aid, disability (if applicable), and other information pertinent to my participation in the
Student Support Services Program at DSLCC. I understand that these records will be used only to assess the
need for program services, discern educational progress, evaluate the effectiveness of the program activities,
and fulfill program reporting requirements.
In addition, I give permission for my photograph/video, work and/or statements to be used by Student Support
Services and/or the college for promotional or publicity purposes.
I affirm to the best of my knowledge that the information I have provided is true.
Student Signature: ______________________________________________________ Date: _________________
Parent/ Guardian Signature: _______________________________________________Date: _________________
OFFICE USE ONLY
Approved ______Not Approved ______Waiting List_______
Director’s Initials: ______
Project Entry Date: __________
Eligibility: LI/FG ______FG ______ LI _____ DS _____ LI/DS ______
Income Verification: FA _____ Tax _______
Academic Need: _____________________________________________________________________
DSLCC Student Support Services
Achievement Center 540-863-2860
Student Support Services is funded through the U.S. Department of Education TRIO programs for
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