“S –departments-SSC-SSS-Forms-SSSApp w/instructions Form Revised May 2019 Student Support Services (SSS) APPLICATION FORM Clarkson University Name: ________________________________________________________________________________ CU ID#___________________________ Last First Middle Home Address: __________________________________________________________________________________________________________ Address City State Zip Clarkson University Address: ___________________________________________________________________________________________ CU Box Number ( if unknown leave blank ) Campus Address Cell Phone: ________________________________ E-mail:______________________________________________________________________ Your current year at Clarkson University: Please circle one TCS FR SO JR SR GRAD US Citizen: Yes No Permanent Resident: Yes No Gender: Male Female Birth Date: _______/________/________ SSN#: last 4 digits _______________ Expected Graduation Year from CU: _____________ Ethnicity: Hispanic/Latino: Yes No Race: Check all that apply American Indian/Alaska Native Asian Black or African American White Native Hawaiian or Other Pacific Islander Parent/Guardian Education Level: Check highest educational level of each parent (check only one). Are you a first generation college student (you were raised in a household where neither parent had a 4 year college degree)? Yes No Father: Grade School only: ______ High School Diploma: ______ College: ______ ______ ______ ___________________ Check only one box for education level 1 yr 2yrs 3yrs 4yrs or above and received Bachelor’s Degree or above Mother: Grade School only: ______ High School Diploma: ______ College: ______ ______ ______ ___________________ Check only one box for education level 1 yr 2yrs 3yrs 4yrs or above and received Bachelor’s Degree or above Currently Reside with: Mother Father Both Independent (file your own income tax) Current Economic Status: Are you receiving Federal Seo/Pell Grant(s) on your CU Financial Aid package? Yes or No or I don’t know Federal SEO Grant $_______________________ Federal Pell Grant $_______________________ Total Taxable Income for your household on your most recent income tax Year: 20________ $_______________ Size of family Unit __________ Low Income according to U.S.Dept.of Ed. - please see chart at:https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html If claimed on parents’ Income Tax, both parents must sign below: If you do not fall under the Low Income levels please write “Not Applicable” on Taxable Income line x _______________________________________________________ x ______________________________________________________________ x _______________________________________________________ x______________________________________________________________ parent print name clearly parent signature Other: At what Year/Grade Level did you enter Clarkson University? ______Year TCS Freshman Sophomore Junior Senior Are you a non-traditional student? Yes No (did you have a gap between high school and college) Are you a transfer student? Yes No What was the name and location of the college you transferred from? ______________________________________ What was your first date of enrollment at the above college? _____________________________________________ Do you have a documented disability? Yes No Are you utilizing CU office of Accommodative Services If you checked yes, please arrange to meet with the Office of AccessABILITY Services once you arrive on campus. I certify that the above information is true and correct to the best of my knowledge. I authorize Student Support Services to request and share my information with regard to my academic, personal, and professional success and financial aid status. I understand that all information will be held in strict confidence by Student Support Services at Clarkson University, Potsdam, NY. x__________________________________________________________________________________________________________ Student Signature Date Please complete and return to Clarkson University Student Success Center, Box 5647 - ERC Suite 1400, Potsdam, NY 13699-5647 if you have questions please call 315-268-2209 • Fax 315-268-1377
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“S –departments-SSC-SSS-Forms-SSSApp w/instructions Form Revised May 2019
Student Support Services (SSS) APPLICATION FORM
Clarkson University
Name: ________________________________________________________________________________ CU ID#___________________________
Last First Middle
Home Address: __________________________________________________________________________________________________________
Address City State Zip
Clarkson University Address: ___________________________________________________________________________________________
CU Box Number ( if unknown leave blank ) Campus Address
Cell Phone: ________________________________ E-mail:______________________________________________________________________
Your current year at Clarkson University: Please circle one TCS FR SO JR SR GRAD
US Citizen: Yes No Permanent Resident: Yes No Gender: Male Female
Birth Date: _______/________/________ SSN#: last 4 digits _______________ Expected Graduation Year from CU: _____________
Ethnicity: Hispanic/Latino: Yes No
Race: Check all that apply
American Indian/Alaska Native Asian Black or African American White Native Hawaiian or Other Pacific Islander
Parent/Guardian Education Level: Check highest educational level of each parent (check only one).
Are you a first generation college student (you were raised in a household where neither parent had a 4 year college degree)? Yes No
Father: Grade School only: ______ High School Diploma: ______ College: ______ ______ ______ ___________________
Check only one box for education level 1 yr 2yrs 3yrs 4yrs or above and received Bachelor’s Degree or above
Mother: Grade School only: ______ High School Diploma: ______ College: ______ ______ ______ ___________________
Check only one box for education level 1 yr 2yrs 3yrs 4yrs or above and received Bachelor’s Degree or above
Currently Reside with: Mother Father Both Independent (file your own income tax) Current Economic Status:
Are you receiving Federal Seo/Pell Grant(s) on your CU Financial Aid package? Yes or No or I don’t know
Federal SEO Grant $_______________________ Federal Pell Grant $_______________________
Total Taxable Income for your household on your most recent income tax Year: 20________ $_______________ Size of family Unit __________
Low Income according to U.S.Dept.of Ed. - please see chart at:https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html If claimed on parents’ Income Tax, both parents must sign below: If you do not fall under the Low Income levels please write “Not Applicable” on Taxable Income line
x _______________________________________________________ x ______________________________________________________________ x _______________________________________________________ x______________________________________________________________ parent print name clearly parent signature
Other: At what Year/Grade Level did you enter Clarkson University? ______Year TCS Freshman Sophomore Junior Senior
Are you a non-traditional student? Yes No (did you have a gap between high school and college)
Are you a transfer student? Yes No What was the name and location of the college you transferred from? ______________________________________ What was your first date of enrollment at the above college? _____________________________________________
Do you have a documented disability? Yes No Are you utilizing CU office of Accommodative Services
If you checked yes, please arrange to meet with the Office of AccessABILITY Services once you arrive on campus. I certify that the above information is true and correct to the best of my knowledge. I authorize Student Support Services to request and share my information with regard to my academic, personal, and professional success and financial aid status. I understand that all information will be held in strict confidence by Student Support Services at Clarkson University, Potsdam, NY.
x__________________________________________________________________________________________________________ Student Signature Date
Please complete and return to Clarkson University Student Success Center, Box 5647 - ERC Suite 1400, Potsdam, NY 13699-5647
if you have questions please call 315-268-2209 • Fax 315-268-1377
“S –departments-SSC-SSS-Forms-SSSApp w/instructions Form Revised May 2019
Clarkson University
Student Support Services (SSS)
Name______________________________________ Student ID# _______________________
Date: _____________________________
STATEMENT OF INCOME VERIFICATION
Current Economic Status:
Whose Income Tax are you filed on? Please answer yes or no to the following:
- I am filed on my Mother’s Income Tax only………………………….._________
- I am filed on my Father’s Income Tax only………………………......._________
- I am filed on Both my Parents Income Tax (joint) ……………………_________
- I file as an Independent (file my own Income tax)? ………………….._________
Total Taxable Income for your household is:
$ ______________ Size of family Unit ________ Information is from what year? 20 ________
OR
________ I did not and will not file a Federal Income tax return, IRS Form 1040 or 1040A for the
year 20__________. I will, if requested, provide official confirmation from the Internal Revenue
Service (IRS) to this effect.
I did not file a tax return for the following reasons: ____ I received no taxable income.
____ Taxable income received was less than the amount required for filing a tax return.
____ Other
I HEREBY SWEAR OR AFFIRM THAT THE INFORMATION REPORTED ON THIS FORM
AND ANY ATACHMENT(S) HERETO IS TRUE, COMPLETE, AND ACCURATE TO THE
BEST OF MY KNOWLEDGE.
STUDENT’S SIGNATURE: ____________________________________ DATE: ____________
PARENT’S SIGNATURE: ____________________________________ DATE: ____________
PARENT’S SIGNATURE: ____________________________________ DATE: ____________
Both parent’s signature required if filing joint
please see reverse side for Federal TRIO Current Low Income Levels or website:
https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html
“S –departments-SSC-SSS-Forms-SSSApp w/instructions Form Revised May 2019
Clarkson University
Student Support Services (SSS)
https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html
“S –departments-SSC-SSS-Forms-SSSApp w/instructions Form Revised May 2019
Clarkson University
Student Support Services (SSS)
Information
What is SSS TRIO?
The purpose of the Student Support Services Program (SSS) is to increase the number of disadvantaged low-
income college students, first-generation college students, and college students with disabilities in the United States
who successfully complete a program of study at the postsecondary level.
We want to give all CU students that qualify for SSS the opportunity to learn more about our program.
How do I qualify for SSS TRIO? One or more of the following criteria allows you to qualify for SSS:
1) A First Generation student (neither parent has a 4-year degree)
2) A student with a Disability (this confidential information is at your discretion to list if you want to qualify
under this criteria – all information is kept confidential)
3) Income eligible – According to Federal Trio Low-Income Levels
https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html
* If you are income qualified, we will need signature(s) from whoever’s most recent Income Tax that you are
claimed on.
* If your parents file a joint tax return we will need both signatures.
* If you do not qualify under Low Income please write NOT APPLICABLE (N/A) on the Taxable Income line.
If you are eligible for SSS under one of the above listed criteria, please compete all of the SSS
application. (Please stop by the SSS office to learn more about our program).
If you are NOT eligible, please fill out the top portion of the application and fill out the
following:
First Generation = NO (Neither parent have a 4-yr degree)
Taxable Income Line = N/A (I do not fall under the Trio Low Income Levels)
Disability = NO (Not claiming to be a student with a Disability)
Please sign and date (If your status changes please fill out another application).
Thank you!!
“S –departments-SSC-SSS-Forms-SSSApp w/instructions Form Revised May 2019
STUDENT SUPPORT SERVICES (SSS)
…… so what can we do for you?
Provide opportunities for academic development
Assist students with basic college requirements
Encourage students toward the successful completion on their postsecondary education
Student Support Services (SSS) may provide grant aid to current SSS participants who are receiving
Federal Pell Grants, are first or second year students and are in good academic standing.
◊ Academic tutoring
◊ Provide one on one academic counseling such as; study skills, time management, test taking tips
◊ Assistance in course selection
◊ Assist with student financial aid programs
◊ Assist with career options
◊ Academic activities
◊ GRE and MCAT preparation
◊ GRE Fee Waivers
If you have any questions about Student Support Services please feel free to contact us at:
Catherine McNamara, Associate Vice President Kate Mikel, Associate Director
Student Success, Diversity & Inclusion Academic Specialist / Tutor Coordinator
Director, Student Support Services Student Success, Diversity & Inclusion
[email protected] [email protected]
Christine Campbell, Associate Director Lorraine Hicks
Academic Specialist / FYS Coordinator Assistant to Associate Vice President
Student Success, Diversity & Inclusion Student Success, Diversity & Inclusion
[email protected] [email protected]
Student Support Services
ERC Suite 1400 • Box 5647 • Potsdam, NY 13699
Phone: 315-268-2209 • Fax: 315-268-1377
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