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TRIO Student Support Services
Application for 2020-21
Please fill out the front and back. If you have questions, call 402 375 7500 or 1 800 228 9972, ext. 7500.
1. Full legal name (please print or type):
Last First Middle Maiden/Other
2. Student ID Number: 3. Date of birth: 4. [ ] Male [ ] Female
5. Permanent home address and phone:
Street Address City State Zip Code (Area Code) Telephone (Area Code) Cell Phone
6. Mailing address (please give campus address and phone, if different from home address):
Street Address City State Zip Code (Area Code) Telephone
7. U.S. citizen? [ ] Yes [ ] No If no, permanent resident? [ ] Yes [ ] No
8. Have either of your parents received a four-year degree from any college or university? [ ] Yes [ ] No
9. Race (select all that apply):
[ ] Native American or Alaskan Native [ ] Native Hawaiian or other Pacific Islander
[ ] Asian [ ] White
[ ] Black or African American
Ethnicity: Hispanic or Latino [ ] Yes [ ] No
10. Have you previously participated in: [ ] Upward Bound [ ] Talent Search [ ] EOC [ ] SSS
If yes, where:
Educational Data Academic performance is used as an indicator of need for services.
11. Please provide the following information about your current school or the last school you attended:
School Name Address City State Zip
12. Do you hold a [ ] high school diploma or [ ] GED Certificate? Date earned:
13. Have you taken the ACT? [ ] Yes [ ] No ACT Composite Score:
14. What is your current academic level? ____in high school [ ] Junior [ ] Senior
____in college [ ] Freshman [ ] Sophomore [ ] Junior [ ] Senior
Medical Data Documentation of disability must be provided before a student is considered for acceptance to TRIO SSS.
15. Do you have a [ ] physical disability or [ ] learning disability or [ ] medical disability?
If yes, please explain:
You must submit documentation of your disability along with this application. You should be able to obtain appropriate
documentation from your doctor, counselor, or healthcare provider.
I certify that any information that I have provided is complete, accurate, and true. I understand that
TRIO Student Support Services
will use the data on this application form (and any documentation materials) to assist in assessing academic needs and that all of the
information will be kept confidential. I understand that the TRIO Student Support Services program serves a limited number of students,
and I may be placed on a waiting list until an opening is available.
Applicant’s Signature Date (month/day/year)
Page 1
Page 2 of the form must also be completed.
Income Eligibility
Federal regulations require income information to determine which applicants meet federal income eligibility guidelines. Income eligibility
is determined by family size and family taxable income. Do not use adjusted gross income.
Please complete the appropriate section below.
Section I. Dependent Students
You are a Dependent Student if you:
1. are under 24 years of age; or
2. lived with and received more than half of your support this past year from parent(s) or guardian(s).
Number of Family Members is defined as:
1. you, your parents, and the dependents of your parents;
2. if your parents are divorced or separated, family members include the parent whose income is used to compute available income for
federal financial aid eligibility and that parent’s dependents, including you.
3. if your parents are divorced and the parent whose income is used for this form is remarried, or if your parent is a widow or widower
who has remarried, family members also include the new spouse and any dependents of the new spouse if that spouse’s income is
included in your parent’s taxable income.
If you are a Dependent Student, please provide:
Parent(s) 2018 Taxable Income: $ Number of Family Members: (see definitions above)
Taxable income is found on the following tax form lines:
1040 line 10
Parent(s) Name:
Parent Signature: Date:
Section II. Independent Students
You are an Independent Student if you:
1. are 24 years of age or older by December 31, 2019;
2. are an orphan or ward of the court or were a ward of the court until age 18;
3. are a veteran of the Armed Forces of the United States;
4. are a graduate or professional student;
5. are a married individual;
6. have legal dependents other than a spouse; or
7. have been approved for independent status by a financial aid administrator.
Number of Family Members is defined as:
1. if you are married: you, your spouse, and your dependents
2. if you are divorced or separated: do not include your spouse (or ex-spouse), but do
include you and your dependents.
If you are an Independent Student, please provide:
Your 2018 Taxable Income: $ Number of Family Members: (see definitions above)
Taxable income is found on the following tax form lines:
1040 line 10
Your Signature: Date:
Send completed application materials to:
Wayne State College
TRIO Student Support Services
1111 Main Street
Wayne, NE 68787
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