EDUCATIONAL OPPORTUNITY CENTER
PARTICIPANT INCOME VERIFICATION FORM
The Educational Opportunity Center (EOC) is a federally funded TR
i
O program and is required by the U.S. Department of Education to obtain income
information for participants. It is important that you complete the form below or provide a copy of your tax return (1040, 1040A, or 1040EZ) for the
current
year. If you are currently married (including legal same sex marriages) income information for both you and your spouse is required. All financial
information will be kept confidential and will only be used for federal reporting purposes.
Participant Name Social Security Number
PARENT EDUCATION INFORMATION
Did the participant’s MOTHER graduate from college with a four-year degree?
YES
NO
UNKNOWN
Did the participant’s FATHER graduate from college with a four-year degree?
YES
NO
UNKNOWN
PARTICIPANT INCOME INFORMATION
Did you complete an IRS income tax return? YES NO
TAX YEAR
What is your adjusted gross income? $
What is your taxable income (if you filed a tax return)? $
As of today, are you currently a dislocated worker? YES NO
How many people are in your household?
How many will be in college during the award year?
What is your marital status as of today? (check one)
Never Married Married Divorced Separated Widowed
Month and year you were married, separated, divorced or widowed /
Check if anyone in the household received any of the following benefits in
2016
2017
2018
(check years benefits received)
Supplemental Security Income (SSI)
Medicaid Benefits
Supplemental Nutrition Assistance Program (SNAP)
Free or Reduced Priced School Lunch
Family Independence (FI)
Special Supplemental Nutrition for Women, Infants, and Children (WIC)
CERTIFICATION AND SIGNATURES
> I/We certify that all the information provided including my
taxable income and/or annual gross income
is correct and true to the best of my knowledge.
Adjusted gross income (AGI) includes the
amount of money earned in a year from
working, wages, and tips. Use the box at the
bottom of this form to locate your AGI on your
tax return.
Taxable income is the amount of income the
federal government will actually tax. Use the box
at the bottom of this form to locate your taxable
income on your tax return.
You are considered a dislocated worker if
you have been laid off from a job or are
currently receiving unemployment benefits, or
are a displaced homemaker.
The household size is the number of people
for whom the individual provides more than 50
percent of their support for the entire award year
(see academic year below for clarification). This
may include people who live in the home,
children who live outside the home, and unborn
children who will receive more than half of the
individual’s support during the award year.
An
award year
begins July
1
of the first year and
ends June 30 of the second year. For example,
the 201
7
-1
8
award year is July
1,
201
7
– June 30,
201
8
.
> I/We understand that the information provided on this application will be held in confidence by
the EOC staff.
> I/We authorize the release of my school and/or financial records to the EOC program, including test scores
and any other academic information and test results necessary to complete the program’s application process.
Student Signature Date
midlandstech.edu/eoc
i
PO Box 2408
i
Columbia, SC 29202
i
803.822 .3749
click to sign
signature
click to edit
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