Fillable EOP Financial Information Form Transmittal/ Signature (Orange County Community College)

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EOP Financial Information Form Transmittal/ Signature (Orange County Community College)

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The information you provide here will be used in the review of your eligibility for the Educational Opportunity Program. It is to your
advantage to provide as much information as possible. Type or print your answers. Mail the completed form with required documents to:
Application Services Center, The State University of New York, State University Plaza, P. O. Box 22007, Albany, New York 12201-2007.
Your information will be transmitted to each of the SUNY campuses listed on page 4 to which you have applied as an EOP candidate.
Questions? Contact the EOP Office at a campus to which you applied (see page 4).
Section 1. Personal Information
Section 2. Exceptions to Income Guidelines
Name: _______________________________________________________
Address: _______________________________________________________
_______________________________________________________
Date of Birth: _______________________________________________________
2018
EOP FINANCIAL INFORMATION FORM
Answer all of the questions below to help determine if you qualify for exclusion from the income eligibility guidelines.
Are you or your family primarily dependent on public assistance payments from Temporary Assistance to
Needy Families (i.e. Family Assistance, Safety Net)? Yes No
Are you in foster care as established by the court? Yes No
Are you a ward of the state or county? Yes No
If you answered “Yes” to either of the last two questions above, skip to Section 8.
All others, continue to Section 3.
Section 3. Dependency Status
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Answer all of
the questions below to help determine your dependency status.
Will you be 24 years of age by December 31, 2018?
Are you married? (Answer “yes” if you are separated, but not divorced.)
Are you currently serving on active duty in the U.S. Armed Forces?
Are you a veteran of the U.S. Armed Forces?
Do you have legal dependents (other than a spouse) who receive more than half of their support from you?
At any time since you turned age 13, were both your parents deceased, were you in foster care or were you
a dependent or ward of the court?
Were you or are you an emancipated minor, as determined by a court?
Were you or are you in legal guardianship, as determined by a court?
At any time on or after July 1, 2017, were you determined to be an unaccompanied youth who is homeless
or to be self-supporting and at risk of being homeless?
Yes No
If you answered “No” to all of the questions above, your status is “Dependent” for the purposes of this form. Continue to Section 4.
If you answered “Yes” to any of the questions above, your status is “Independent” for the purposes of this form. Skip to Section 5.
U.S. Citizen: Yes No If no, permanent resident: Yes No
Applicant ID Number:
High School CEEB Code:
Entry Term:
Date:
_____________________
_____________________
_____________________
_____________________
6.5K
Questions? Contact the EOP Office at a campus to which you applied (see page 4).
Dependent students must complete this section. Independent students should leave this section blank.
What is the current marital status of your parents? Married Single/Never Married
Divorced/Separated Widowed
Unmarried and both parents living together
Date of Marital Status (mm/yyyy): ________________________
Who provided your financial support during the past 12 months? Parent(s)
Other: ___________________________________
Section 4. Parent Information - FOR DEPENDENT STUDENTS ONLY
Section 5. Household Information
Section 6. Additional Household Income
Report all additional income received in your household for the 2015 tax year.
Dividends, interest, rents or other income from investments: $ ___________________________
Social Services/Public Assistance (TANF, etc): $ ___________________________
Social Security benefits: $ ___________________________
Supplemental Security Income (SSI): $ ___________________________
Workers Compensation/Disability: $ ___________________________
Pension/Annuity: $ ___________________________
Unemployment: $ ___________________________
Alimony/Maintenance: $ ___________________________
Child Support: $ ___________________________
Other income (specify): $ ___________________________
2
SelfApplicant
Provide the following information for all household members. A household member is anyone who currently lives at your home with you,
as well as anyone who is dependent on the same income as you, even if that person does not live at your home. If there are more than 10
members in your household, attach a separate sheet providing the same information for each additional person in your household.
Name Age Relationship Employment Annual Filed a Dependent on the
Status Pay before
201
6 federal same income that
Taxes tax return? supports you?
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
__________________________ ____ _____________ _____________ ____________ Yes No Yes No
Questions? Contact the EOP Office at a campus to which you applied (see page 4).
Section 7. Household Assets
Report the current value of the following assets held by your household. Independent students are not required to report information
regarding assets held by parents.
Your cash, checking and savings accounts: $ ______________________
Your investments (non-retirement): $ ______________________
Spouse’s cash, checking and savings accounts: $ ______________________
Spouse’s investments (non-retirement): $ ______________________
First Parent or Stepparent’s cash, checking and savings accounts: $ ______________________
First Parent or Stepparent’s investments (non-retirement): $ ______________________
Second Parent or Stepparent’s cash, checking and savings accounts: $ ______________________
Second Parent or Stepparent’s investments (non-retirement): $ ______________________
Purchase Year Purchase Price Current Debt
Business or farm owned by you, your spouse or your parents: ____________ $ ________________ $ ________________
Home owned by you, your spouse your parents: ____________ $ ________________ $ ________________
Other real estate owned by you, your spouse or your parents: ____________ $ ________________ $ ________________
3
Section 8. Academic Background
Section 9. Personal Essay
Some of the campuses to which you have applied may require a Personal Essay. If you have applied to any campus marked with an
asterisk (
*
) on page 4, please provide a response to the following questions (up to 500 words) to help us better understand your interest
in EOP. Attach your response to this form. Be sure to include your name on the attachment.
1.) What motivated your interest to pursue post-secondary education?
2.) Explain the circumstances that affected your academic performance in high school.
3.) Based on what you know about the Educational Opportunity Program, how do you think the program will benefit you?
Section 10. Certification
I understand that I must be academically and economically eligible for EOP and that I must provide required documentation with this
form to
prove my eligibility. I understand that I am required to file the 2018-19 Free Application for Federal Student Aid (FAFSA) as
soon as possible after October 1, 2017. I understand that additional paperwork may also be required.
All information submitted is true to the best of my knowledge. I understand that any knowing falsification or omission of data may result
in the denial of admission or dismissal.
Applicant Signature: ________________________________________________ Date: __________________
First Parent or Stepparent’s Signature: ________________________________________________ Date: __________________
Second Parent or Stepparent’s Signature: ________________________________________________ Date: __________________
Less than a high school diploma High school diploma (or equivalent)
Some college, no degree Associate degree Bachelor’s degree or higher
Less than a high school diploma High school diploma (or equivalent)
Some college, no degree Associate degree Bachelor’s degree or higher
Please indicate if you currently participate in any of following programs:
Educational Opportunity Center (EOC) GEAR-UP Talent Search Upward Bound
Early College, Middle College or Gateway to College STEP Liberty Partnership TRIO
Indicate the highest level of education
attained by First Parent:
Indicate the highest level of education
attained by Second Parent:
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Questions? Contact the EOP Office at a campus to which you applied (see above).
Required Financial Documentation
Mailing Instructions
Campus Contacts
These SUNY Campuses accept this SUNY EOP Financial Information Form. Campuses marked with an (
*
) require the
Personal Essay described in Section 9.
Mail your completed SUNY EOP Financial Information Form together with required documents to: Application Services Center,
The State University of New York, State University Plaza, P.O. Box 22007, Albany, New York 12201-2007. Your information will be
transmitted to each of the SUNY campuses listed below to which you have applied as an EOP candidate. Your completed form must
include the following:
This SUNY EOP Financial Information Form
Your required financial documentation (see above)
Your Personal Essay, if required (see Section 9)
You must attach the following documents for the tax year _______________ to verify the information reported. Please do not return
this form until the required documents are available.
If you reported: You must attach:
No Income • IRS Form 4506-T (Request for Transcript of Tax
Return, Verification of Non-Filing)
Income from wages, tips, dividends, interest, rental, business profits • IRS forms 1040, 1040A, 1040EZ, signed copies of
1040TEL or official transcript of tax returns; and
• Forms W-2, 1099, W9
Income from disability benefits, a pension, annuity, or • Letter from the appropriate institution stating
unemployment benefits applicable year’s total award (if not already reported
on a tax return)
• Disabilities Statement
Child support, maintenance or alimony • Signed affidavit, court order or legal document
indicating amount of child support and/or alimony
Public Assistance • A signed letter from the agency stating applicable
year’s total award and names of recipients
Social Security, Supplemental Security Income or Veteran’s • SSA Form 1099 or letter from the agency
Administration non-educational benefits stating applicable year’s total award for each member
of the household including names of individuals
You are a ward of the court, foster child or orphan • Letter or court document from the government, courts,
private agency responsible for your support
You are a U.S. Veteran • Form DD214
You are a non-U.S. citizen and a permanent resident • Form I-551 (Alien Registration Card)
You or your family owns a business • IRS Form 1040 Schedule C
Unusual circumstances • Notarized letters, statements, death certificates, etc.
that corroborate claims
4
Campus Contact Number
SUNY Adirondack 518.743.2264
Alfred State College 800.425.3733 x2
Buffalo State College 7
16.878.4017
SUNY Canton
315.386.7123
SUNY Cobleskill 800.295.8988
SUNY Cortland 607.753.4711
SUNY Fredonia 800.252.1212
Finger Lakes Community College 585.785.1390
Fulton-Montgomery Community College 518.7
36.3622
Campus Contact Number
Morrisville State College 315.684.6046
SUNY New Paltz 845.257.3220
Niagara County Community College 716.614.6222
Old Westbury 516.876.3068
SUNY Oneonta 800.SUNY.123
Orange County Community College 845.341.4407
SUNY Oswego 315.312.2250
SUNY Potsdam 315.267.2180
2016
*
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EOP Financial Information Form Transmittal Signature (Orange County Community College)

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Completed 23 July 2020

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