Fillable Golden LEAF Scholars Program (Johnston Community College)

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Golden LEAF Scholars Program (Johnston Community College)

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BROWSE JOHNSTON COMMUNITY COLLEGE FORMS

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1
Golden LEAF Scholars Program
Potential candidates must meet the following guidelines:
Resident of a NC county listed on Attachment I
Meet the Federal TRIO Program requirement listed on
Attachment II
Provide a SIGNED 2019 Federal Tax Return
***If you did not work during 2019, please complete a Non-Employment Attestation form
(see attached checklist).
***If you worked during 2019, but did not file taxes, please complete a Student Non-Tax
Filer Attestation form (see attached checklist) and submit a copy of your 2019 W-2s.
Provide completed Golden LEAF application and all
attached waivers
Provide a working email address for correspondence
Award amounts may vary depending upon
availability.
Maximum award amount will not exceed
$1000.00
Deadline for application:
Thursday, February 25, 2020 at 5:00 pm
Application must be submitted to:
Workforce Development Center
135 Best Wood Drive, Clayton, NC
OR
JCC Front Desk Receptionist at the Wilson Building
Main Campus
2
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North Carolina Community Colleges
Golden LEAF Scholars Program – Two-Year Colleges
2020-2021 Student Application
Instructions: Complete this application and return the completed application to the college’s Financial
Aid Office. Eligible students must reside in a rural county that is tobacco dependent, or economically
destressed, as determined by the Golden LEAF Foundation (Please see your school’s financial aid office
for a list of 2020-2021 Qualifying Counties).
Personal Information:
Full Name:
Student ID 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 more than 10 years
(To be eligible for this scholarship, your permanent residence must be in an approved NC county.)
Educational Information:
College you are attending:
Occupational 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, if any.
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Use of Funds:
Tuition Fees Books Supplies Credentialing Exams
Childcare Transportation
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
4
College Media Consent Agreement
Golden LEAF Scholars Program – 2-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)
5
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
6
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, 2019.
• 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, 2019.
Full Name
Age
Relationship
7
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 2019 tax return (W-2s alone are NOT acceptable)
OR
Signed “Non-Tax Filer Attestation” with 2019 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 2019.
(print first & last name)
Student signature: _________________________________ Date: _______________
Student Non-Employment Attestation
I, _________________________________, affirm I was NOT employed during the 2019
(print first & last name)
tax year and did NOT receive any government assistance (ex. SAP, TANF, WIC,
disability, etc).
Student signature: _________________________________ Date: _______________
8
Attachment I
Golden LEAF Scholars Program – Two Year Program
Qualifying Counties
Alamance
Granville
Person
Alexander
Greene
Pitt
Alleghany
Halifax
Randolph
Anson
Harnett
Richmond
Ashe
Haywood
Robeson
Avery
Hertford
Rockingham
Beaufort
Hoke
Rowan
Bertie
Hyde
Rutherford
Bladen
Jackson
Sampson
Burke
Johnston
Scotland
Caldwell
Jones
Stanly
Camden
Lee
Stokes
Caswell
Lenoir
Surry
Catawba
Lincoln
Swain
Cherokee
Macon
Transylvania
Chowan
Madison
Tyrell
Clay
Martin
Vance
Cleveland
McDowell
Warren
Columbus
Mitchell
Washington
Craven
Montgomery
Wayne
Davidson
Nash
Wilkes
Davie
Northampton
Wilson
Duplin
Onslow
Yadkin
Edgecombe
Onslow
Yancey
Franklin
Pasquotank
Gates
Pender
Graham
Perquimans
Scholarships are limited to students who demonstrate financial need and reside in a rural county that is
economically distressed and/or tobacco dependent. A scholarship recipient who resides in an eligible county upon
initial award will retain eligibility and will be eligible for renewal awards as long as the student’s place of residence
is within the state of North Carolina and the other scholarship eligibility criteria are met.
9
Attachment II
Federal TRIO Programs
Current-Year Low-Income Levels
(Effective January 28, 2015 until further notice)
Size of Family Unit
48 Contiguous States,
D.C., and Outlying Jurisdictions
1
$18,090
2
$24,360
3
$30,630
4
$36,900
5
$43,170
6
$49,440
7
$55,710
8
$61,980
For family units with more than eight members, add the following amount for each additional family
member: $4,180 for the 48 contiguous states, the District of Columbia and outlying jurisdictions.
The term “low-income individual" means an individual whose family's taxable income for the
preceding year did not exceed 150 percent of the poverty level amount.
The figures shown under family income represent amounts equal to 150 percent of the family
income levels established by the Census Bureau for determining poverty status. The poverty
guidelines were published by the U.S. Department of Health and Human Services in the Federal
Register on January 22, 2015.
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