Verification Information:
Employed?
No Yes – Where ________________________________________________________
Check the amount below which best matches your current household’s level of taxable income: (To select an amount,
please refer to tax forms 1040EZ-line 6, 1040A-line 26, or 1040-line 43 ** leave bank if unknown**)
0 – $17,820 $17,821 – $24,030 $24,031 – $30,240
$30,241 – $36,450 $36,451 – $42,660 $42,661 – $48,870
$48,871 – $55,095 $55,096 – $61,335 Over $61,335
Total number in your household:
Disability: **Please note this section is VOLUNTARY and not required to submit the application. Please check the
box to acknowledge you understand this information is not required**
[Voluntary] Do you have any type of disability (i.e. physical, medical, psychological, learning, attention
deficit) or were you ever in a special education program in school? Yes No
[Voluntary] Are you aware we have an Office of Accommodative Services on the 3
rd
floor of the Shepard
Center? Yes No
I certify that the above information is true and correct to the best of my knowledge. In addition,
everything mentioned in this application packet—(all forms) are verified by this signature. I hereby
authorize Student Support Services to obtain all academic and financial information necessary to
determine my eligibility.
Applicant Signature: Date:
OCCC is an equal opportunity/affirmative action institution.
OFFICE USE ONLY: Date Application Received:___________
Eligibility requirements met: First Generation / Income / Disability
Student Accepted Yes No Date:______________ Staff Initials____________
Reason Accepted_________________________________________________ APR #
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