ࡱ>  bjbj6!6! (TK?kTK?k&6 4SSShSi&Z'7'hhhhhhhgmpPhG'c&^&G'G'h iC/C/C/G'j8hC/G'hC/C/^l*bM><'Zr_*hi0i_mp )FmpT*b*bmpcG'G'C/G'G'G'G'G'hhQ,G'G'G'iG'G'G'G'mpG'G'G'G'G'G'G'G'G' :  Applicant: ____________________________________________________________ ____________________ Last Name First Name M.I. Student ID Number Permanent Address: Street City State Zip Address While at School: Cell Phone: Permanent Phone: Work/Alternate Phone: NWC Email Address: Alternate Email Address: ____________________________________ Demographic Information: Date of Birth: Current age: Gender: M / F Ethnicity: Are you Hispanic or Latino/a? q Yes q No Race: Please check ALL that apply q American Indian or Alaskan Native q Asian q Black or African American q White q Hawaiian or Other Pacific Islander How did you hear about NWC Student Support Services? _________________________________________________ Academic Information: Have you been accepted to or are you currently enrolled at NWC? q Enrolled q Accepted for (semester) _____________ Major: Career Plans: _____________________________________________________ Academic Need: Please mark all that apply. q I am a first-generation student, income qualified student or a student with a disability. q I had a high school GPA below 2.0. q I have been out of school for 5 or more years. q I tested into pre-college math or English. q I have limited English proficiency. q I currently have college grades of C- or below. q I lack educational or career goals. q I have my high school equivalency. q I lack academic preparedness for college level coursework. q I currently have failing grades. q I need academic support to raise my grades. Eligibility for Program Services 1. Citizenship/Residency Status: Are you a citizen or national of the U.S qYes qNo If  No, do you meet the residency requirements for Federal student financial assistance? qYes qNo (If your answer to both questions is  No, you are not eligible to join TRIO Student Support Services as it is a federal grant from the US Dept. of Ed. We encourage you to contact our office to see if we can help you locate other student services programs.) 2. Degree Status: Do you currently have a Bachelor s Degree? qYes qNo If yes, please explain why you are pursuing a certificate or degree at NWC. 3. First Generation College Student: Did your mother graduate with a bachelor s degree from a four-year college or university? qYes qNo Did your father graduate with a bachelor s degree from a four-year college or university? qYes qNo If you didn t live with both of your parents, which parent/guardian did you live with most? _______________________________ 4. Physical, Cognitive, Learning or Psychological Disability Do you have a physical, cognitive, learning, or psychological disability? qYes qNo Are you registered with NWC Disability Support Services? qYes qNo 5. Income Eligibility: Complete Section a or b below. a) Dependent Students: You are considered a Dependent Student if you mark either of the situations below: q I am under 24 and don t meet the independent student qualifiers (shown below in b). q I was claimed on my parents income tax return. Your parents must complete and sign the attached Verification of Parental Income. b) Independent Students: You are considered an Independent Student if you can mark any of the situations below: q I am 24 years of age or older. q I am a veteran. q I am married. q I have dependents other than my spouse. q I am an emancipated minor. q I have designated homeless student status. q I have a legal guardian other than my parents. q I have been an orphan, in foster care, or a ward of the court after the age of 13. What was your taxable income on the most recent year s income tax return (not gross or adjusted gross income)? This information can be found on Tax Form 1040 Line 15 (or a line close to that). Taxable Income $ ________________ Receiving a Pell Grant? qYes qNo Pell Amount? $_______________ What is the total number of family members claimed on your tax return? ___________ Your signature on this application indicates that this is an accurate statement of taxable income as reported on your most recent tax return. Records Release Statement and Signature: In order to track the progress of TRIO Student Support Services (SSS) participants throughout their college career, SSS staff will access records and information on current and past academic standing, coursework, interim or final grades, attendance, placement scores, college enrollment status, scholarship or financial aid application and award status, and official or unofficial transcripts. In order to remain compliant to this federally funded grant, we are required to access and report student educational data including GPA, enrollment status (at NWC or elsewhere), degree status, income and/or first-generation status with the US Department of Education. I authorize the SSS Program to obtain information on my financial aid and academic records, including enrollment in and progress toward degree for any institution in which I enroll, for grant reporting purposes. I understand that this information is to be used for appraising the effectiveness of the SSS program and services, increasing the effectiveness of the program, to maintain active grant status, and to determine current and future participation status. By submitting this form, I am certifying that all of the information provided on this form is correct and complete to the best of my knowledge. (_________________________________( _____ Print Full Name Signature Date Verification of Parental Income (Dependent Students Only) Funding for TRIO Student Support Services is provided by the US Department of Education. The USDE requires proof that funds are serving those for whom they are intended. 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Falling above these guidelines does NOT in itself eliminate you from our program. Student claimed as dependent: ___________________________________ Last Name First Name  Parents taxable income (not total income or adjusted gross income) for the Most Recent TAX YEAR (found on Tax Form 1040, Line 15) was: $ ____________________ Total number of family members claimed on parents /guardians tax return: ________________________ Is student receiving a Pell Grant? Yes No If yes, Pell Amount: _____________________________ I understand that this information is confidential and is used to verify program eligibility requirements only and will not be used or released for any other purpose. I certify that this information is accurate and complete to the best of my knowledge. _________________________________________ ____________________________________ Parent/Guardian Printed Name Relationship to Student ____________________________________ ____________________________________ Signature Date *Income-Eligibility Chart Funding for TRIO Student Support Services is provided by the U.S. Department of Education. The USDE requires proof that funds are serving those for whom they are intended. For that reason, documentation of your eligibility status is required. If the TAXABLE INCOME (not adjusted gross income) on your income tax form is less than the amount shown on the chart below, you are considered income-eligible. Taxable income above these guidelines does not necessarily eliminate you from qualifying for our program as you may qualify as first-generation or student with a disability. Federal TRIO Programs Current-Year Low-Income Levels (EffectiveJanuary 13, 2026until further notice.) Size of Family Unit48 Contiguous States, DC, and Outlying JurisdictionsAlaskaHawaii1$23,940$29,925$27,5402$32,460$40,575$37,3353$40,980$51,225$47,1304$49,500$61,875$56,9255$58,020$72,525$66,7206$66,540$83,175$76,5157$75,060$93,825$86,3108$83,580$104,475$96,105 For family units with more than eight members, add the following amount for each additional family member: $8,520 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $10,650 for Alaska; and $9,795 for Hawaii. 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 2026 poverty guidelines were published by the U.S. Department of Health and Human Services in the Federal Register on January 15, 2026, and are effective as of January 13, 2026. 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