TRIO-SSS Application

TRIO-SSS Student Application

*Indicates a required field
TRIO-SSS is 100% funded by the United States Department of Education is hosted by Iowa Lakes Community College. Funding for 2023-24 is $348,489.
Part 1: Personal Data
Name*

First NameMiddle InitialLast Name
YesNo
Campus*
Room Number
What program are you enrolled in at Iowa Lakes?*
Local Address*

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
Permanent Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Social Security Number (xxx-xx-xxxx)*
MaleFemale
Date of Birth*

MonthDayYear
YesNo
If you answered “NO”, are you an eligible non-citizen? Alien Registration #:
American Indian or Alaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhite
ESL (English as a second language)VeteranFoster ChildHomeless
YesNo
If yes, where?
Degree/Certificates you received there:
What program did you study?
Talent SearchUpward BoundStudent Support ServicesOther
YesNo
YesNo
Part 2: Need
Low high school gradesAcademic Proficient TestsFailing gradesLimited English proficiencyLow college gradesLow admission test scoresLack of academic preparedness for college level workNeed for academic support to raise grade(s)/tutoringOut of academic pipeline for 5 or more yearsLack of clear educational and/or career goalsOther
Part 3: Verification
YesNo
AccommodationsVocationalRehabilitationSAVEOther
YesNo
Part 4: First Generation Student Verification
The term “first generation college student” means:
a. An individual whose parents did not complete a baccalaureate (bachelor’s or 4-year college) degree, or
b. In the case of an individual who regularly resides with and receives support from only one parent, that parent did not complete a bachelor’s or4-year college degree
FatherMotherNeither parent has a 4 year degree
YesNo
Part 5: Dependency and Financial Verification
Dependent Student - Typically younger than 24, unmarried, parental income is reported on the FAFSA. We need YOUR PARENTS’ taxable income amount from the previous yearIndependent Student - An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.
Independent Student Status
Have children/dependents you supportCurrently Active Duty or U.S. VeteranAt risk or considered Homeless by School/HUDOrphan/Ward of CourtOver the age of 24In legal guardianshipMarriedEmancipated minorMasters or Doctorate program
A: Students taxable income amount for the previous year:*
B: Total number of individuals in household (Include parent(s), yourself, and other dependents).*
Dependent Student Status
If you are considered a dependent student, please have your parents complete the TRIO-Student Support Services Financial Eligibility Verification Form. This form needs to be completed and returned before we can process your application. The form can be returned to room 9 on the Estherville campus or room 240 on the Emmetsburg campus.
Total Number of Individuals in household?*
(1) Parent/Guardian Name*

First NameLast Name
Phone/Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Part 6: Release of Information & Affidavit of Truth Statement
By signing this application, I verify that the information provided on both sides are true and accurate to the best of my knowledge. I authorize TRIO-SSS staff to gather and verify information concerning the eligibility and grant aid requirements for the program; financial aid FAFSA information, income, dependency status, and documented disability. I also grant permission for TRIO-SSS staff to access and gather information concerning my academic records, academic progress, class attendance, and allow collaboration with ILCC faculty and staff concerning all of the above.
Student Signature*

Clear
Electronic Signature Agreement: You agree your electronic signature is the legal equivalent of your manual signature on this application. You agree that your signature on this document is as valid as if you signed the document in writing.
Today's Date

MonthDayYear
Date
Should be Empty:

TRIO-SSS Student Application

Part 1: Personal Data

Part 2: Need

Part 3: Verification

Part 4: First Generation Student Verification

Part 5: Dependency and Financial Verification

Independent Student Status

Dependent Student Status

Part 6: Release of Information & Affidavit of Truth Statement