Golden LEAF Scholars Program
Workforce Continuing Education student eligibility:
Reside in North Carolina
Student enrolling in WCE pathways/courses offered for 96 hours or
more & leading to a State or industry-recognized credential
Student is:
o Unemployed
o Has received notification of a pending layoff
o Working and is eligible for the Federal Earned Income Tax Credit
(FEITC); or
o Working and earning wages at or below two hundred percent
(200%) of the federal poverty guidelines
Provide a SIGNED 2017 Federal Tax Return
***If you did not work during 2017, please complete a Non-
Employment Attestation form (see attached checklist).
***If you worked during 2017, but did not file taxes, please complete a
Student Non-Tax Filer Attestation form (see attached checklist) and
submit a copy of your 2017 W-2s.
Provide completed Golden LEAF application and all attached waivers
Provide a working email address for correspondence
Maximum award amount is $250.00
Deadline for application:
Monday, June 8, 2020 at 4:00 pm
Application must be submitted to:
Workforce Development Center
135 Best Wood Drive, Clayton, NC
OR
JCC 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: _____________________________________________________________
Workforce 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 Program2 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,
2020.
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, 2020.
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: _______________
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