OFFICE USE ONLY
UNIVERSITY OF NORTHERN IOWA
Counselor Assigned:
Basis of Eligibility:
9 LI/FG 9 Disabled
(9 PH 9 LD)
9 LI only 9 Disabled & LI (9 PH 9 LD)
9 FG only 9 Not Eligible
STUDENT SUPPORT SERVICES
APPLICATION
PLEASE PRINT
Last Name
First Name
Local Address
Middle Name
Nickname
Permanent Address
City
State
Zip Code
City
State
Permanent Phone
Local Phone
area code
(
Zip Code
area code
)
(
)
Cell Phone
Email
area code
(
)
Social Security Number
__ __ __
UNI Student ID No. Are you a U.S. Citizen?
9 Yes
9 No
- __ __ - __ __ __ __
Birthdate
Gender
month
/
day
/
year
9 Male
9 Female
If No, are you a permanent resident of the U.S., or have
you applied for citizenship?
9 Yes (residency number:
)
9 No
Ethnic Background
9 American Indian / Alaskan Native
9 Asian
9 Black / African-American
9 Hispanic / Latino
Do you have a physical or learning disability?
9 Yes (please specify: _____________________________)
(you must provide documentation from a doctor)
9 No
9 White / Caucasian
9 Native Hawaiian / Other Pacific Islander
9 Other _____________________________
Have you been to UNI’s
Office of Disability Services?
Have you been to
Vocational Rehabilitation?
9 Yes
9 No
9 Yes
9 No
PLEASE CONTINUE
Student Support Services
007 Innovative Teaching & Technology Center
Cedar Falls, Iowa 50614-0388
###
(319) 273-2179
Do you receive financial aid?
First semester enrolled at UNI
9 Yes
9 No
month
Did you enter UNI as:
9 new from high school
9 out of high school 1-4 years
9 out of high school 5+ years
9 transfer student (from where?)
/
Have either of your parents earned a bachelor’s degree?
9 Yes
9 No
year
(please circle which: Mother / Father / Both)
Are you a former participant of Student Support Services, Upward Bound, Upward
Bound Math/Science, Educational Talent Search, or Educational Opportunity Center?
9 No
9 Yes (name of program? _______________________________________________________)
_________________________
(school? ________________________________________________________________)
(name of school)
Classification
9 Freshman
What is your major?
9 Sophomore
9 Junior
9 Senior
What is your career goal?
What are your main objectives in coming to Student Support Services?
9 Course selection and academic advising
9 To get help in a course I am now taking
9 Career planning / counseling
9 Other:
How did you hear about us?
9 Student Support Services (SSS) Staff
9 SSS Peer Assistant
9 Educational Opportunity Center (EOC) Staff
9 Educational Talent Search (ETS) Staff
9 Upward Bound (UB) Staff
9 Upward Bound Math & Science (UBMS) Staff
9 SSS Student
9 UNI Faculty / Staff
9 Admissions Office
9 Academic Advising
9 Committee on Admissions &
Retention (CAR)
9 Office of Disability Services
9 Vocational Rehabilitation
9 Associate Vice President’s Office
9 Academic Achievement &
Retention Services
9 Other (please specify) _____________
____________________________
Income Eligibility
All students applying to the Program must provide proof of income.
Dependent students should provide a copy of their parents’ most recent year’s Federal income tax form and
have their parents complete the Income Verification Form. Independent students should provide a copy of
their most recent year’s Federal income tax form and complete the Income Verification Form.
See the Income Verification Form to determine if you are a dependent or independent student.
The University of Northern Iowa Student Support Services Program requests this information for the purposes of determining
your eligibility and providing the services which you are requesting. No personal, identifiable information is provided to
anyone outside the Program, except with your permission. Failing to provide the required information may prevent us from
providing the services that you request. Your signature on this form is your assurance that, to the best of your knowledge,
all information provided is true and accurate at this time.
Student Signature
Date
month
/
day
/ year
Staff Initials
The University of Northern Iowa is an equal opportunity educator and employer with a comprehensive plan for affirmative action.
3/9/11
UNIVERSITY OF NORTHERN IOWA
STUDENT SUPPORT SERVICES
Income Verification Form
This form is used strictly for the purpose of determining your eligibility for participation in the Student Support Services
program. All students applying for admission must provide signed documentation to verify income. This form must be
completed prior to any consideration given to your request for participation.
Number of family members living in your
household including yourself?
Student's name (please print)
PART I: DEPENDENT STATUS
The five questions listed below will help you determine whether your income or your parents’ income should be
reported on the Income Verification Form.
YES
9
9
9
9
9
NO
9
9
9
9
9
Are you 23 years of age or older?
Are you a veteran of the U.S. Armed Forces?
Are you married?
Are you an orphan or a ward of the court, or were you a ward of the court until age 18?
Do you have legal dependents (other than a spouse)?
Independent Status: If you answered "YES" to one or more of the questions, you must complete Parts III and IV of this form.
Dependent Status: If you answered "NO" to all five questions, your parents must complete Parts II, III, and IV of this form.
PART II: FAMILY INFORMATION (Please print)
(This box is to be completed by dependent students only.)
Names of parents/guardians who claimed you on their income tax return.
Mother's/guardian's name
Address
Phone number
Father's/guardian's name
Address
Phone number
PART III: ANNUAL INCOME INFORMATION
TAXABLE INCOME
PLEASE ATTACH A SIGNED COPY OF YOUR
MOST RECENT FEDERAL INCOME TAX FORM.
(Taxable income is found on: 1040 Line 43, 1040A Line 27, 1040EZ Line 6 on both 2012 and 2013 tax forms)
IF YOU DID NOT FILE A TAX RETURN, PLEASE INDICATE
YOUR SOURCE OF NON-TAXABLE INCOME AND
ATTACH A COPY OF YOUR NON-TAXABLE INCOME DOCUMENTS.
Source(s) of non-taxable income:
‘ Title XIX (Medicaid)
‘ Untaxed pensions
‘ Veterans' benefits
‘ Other (please specify)
‘ Family Investment Program (FIP)
‘ Child support
‘ Untaxed Social Security benefits
‘ I received no taxable income during the
$
Taxable Income
NON-TAXABLE
INCOME
$
Non-Taxable Income
last year, and have no documentation.
PART IV: VERIFICATION (Signature required)
I verify that the income provided is an accurate statement of my income for the last federal income tax filing year.
Signature of person(s) whose income is being reported
Social Security Number(s)
Date
DON'T FORGET TO ATTACH A SIGNED COPY OF INCOME DOCUMENTS
OFFICE USE
Family Size
US DOE Income $
Family’s Income $
Low Income?
Y / N Verified by______
3/9/11
UNIVERSITY OF NORTHERN IOWA
STUDENT SUPPORT SERVICES
AUTHORIZATION FOR RELEASE OF INFORMATION
This is to notify you that I am a participant in the Student Support Services program and would
like for my records in the Registrar’s Office to indicate that I am a participant.
PLEASE PRINT:
Last Name
First Name
Middle
UNI Student ID Number
I also authorize the University of Northern Iowa’s faculty and the Offices of Admissions, Registrar,
and Financial Aid to release application, transcript, midterm evaluation, and financial aid information
from my records to the Student Support Services program for advising purposes.
Other information to be released:
Please send the requested information to:
Nick Sullivan, Director
Student Support Services
University of Northern Iowa
007 Innovative Teaching & Technology Center (ITT)
Cedar Falls, IA 50614-0388
Signature of Student
Date
3/11
University of Northern Iowa
Student Support Services
A TRIO Program sponsored by the University of Northern Iowa and 100% funded by the U.S. Department of Education.
Program Purpose
In July 1984, Student Support Services (SSS) was established at the University of Northern Iowa to provide
services to eligible college students. Program services are designed to increase the retention and graduation
rates of participants, increase the transfer rate of eligible students from two-year to four-year colleges, and
foster an institutional climate supportive of their success.
Participant Eligibility
Program Services
The Student Support Services Program is a federally
funded program which serves 200 eligible University of
Northern Iowa students. To be considered for the
program, a student must be:
The following free services are offered to participants:
 a citizen or national of the United States or meet the
residency requirements for Federal student financial
assistance.
 Personal guidance
 enrolled at the University of Northern Iowa or
accepted for enrollment in the next academic term.
 Academic advising and assistance with course
selection
 Tutoring and study groups
 Financial aid information and application
assistance
 Career advising
 in need of academic support in order to successfully
pursue a post-secondary educational program.
 Assistance with educational and long range
planning
 Î eligible based on federal income guidelines;
Ï a first generation student (neither parent has a
bachelor’s degree); or Ð an individual who has a
disability.
 College survival and study skills workshops
To Request More Information or an Application
 Academic and cultural activities designed to
enhance the student’s personal and intellectual
development
 Assistance in applying to a graduate school or
professional program
Please direct all inquiries and requests to:
Nick Sullivan, Director
Student Support Services Program
University of Northern Iowa
007 Innovative Teaching & Technology Center
Cedar Falls, IA 50614-0388
Phone: (319) 273-2179
Fax: (319) 273-2982
E-Mail: trio-sss@uni.edu
Upon request, this information is available in an alternate media.
The University of Northern Iowa is an equal opportunity educator and employer
with a comprehensive plan for affirmative action.
3/11