Name: __________________________________________________________________________ GCC Student ID: ____________________
(Last) (First) (MI)
Current Address: ________________________________________________________________________________________________________
(Street/P.O. Box) (City) (State) (Zip)
E-mail ________________________________________ Home Phone: ( ) _________________ Cell Phone: ( ) _________________
Gender: ____ Male ____ Female Date of Birth: _______/_______/_________ Social Security Number: ________ - ______ - ___________
Ethnicity: Would you identify yourself as Hispanic/Latino (Please circle) YES NO
Race: Please check all of the following that apply to you: _____ American Indian/Alaskan Native _____ Asian _____ Black/African American
_____ White _____ Native Hawaiian/Other Pacific Islander
Marital Status: _____ Single _____ Married Number of Children (if applicable): _____
Veteran Status: Are you a veteran? _____ YES _____ NO
Are you a U.S. citizen? _____ YES _____ NO If NO, are you a Resident Alien? _____ YES _____ NO
Are you an individual with a documented physical and/or learning disability? _____ YES _____ NO
If YES, is the disability documentation on file with GCC’s Office of Disability Services? _____ YES _____ NO
Does your father/legal guardian have a four-year college degree? _____ YES _____ NO
Does your mother/legal guardian have a four-year college degree? _____ YES _____ NO
The parents’ (or legal guardian’s) federal tax return must be used if they claimed the student as a dependent on their 2018 or 2019 income tax
return, or if the student was under 24 years of age, single and not a veteran.
If this applies to you - Please enter your parent’s 2018 or 2019 TAXABLE INCOME
(Form 1040 line 10, 1040A line 27, 1040EZ line 6) $__________________
Please enter the number of exemptions claimed in 2018 or 2019
(Form 1040 line 6d, 1040A line 6d, 1040EZ line 5) ________
The student’s federal tax return must be used if the student was not claimed as a dependent and was 24 or older, or is a veteran, or was
married (spouse’s 2018 or 2019 income should be included if applicable).
If this applies to you - Please enter the student’s 2018 or 2019 TAXABLE INCOME
(Form 1040 line 10, 1040A line 27, 1040EZ line 6) $__________________
Please enter the number of exemptions claimed in 2018 or 2019
(Form 1040 line 6d, 1040A line 6d, 1040EZ line 5) ________
In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect
information to implement the Student Support Services Program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In
accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services program. The principal purpose
for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing the information on this form, including a social
security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information
that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties.
Jessica Leinon-Novascone, Director
TRiO-Student Support Services
E4946 Jackson Road – T105E
Ironwood, MI 49938
jessicaln@gogebic.edu
TRiO-Student Support Services
APPLICATION 2020-2021
