Student Support Services Application - University of Maine at Fort Kent

Applicant Information
Last Name:	First Name:	MI:	Student ID:
Address:	City:	State:
Zip Code:	Telephone Number:
Date of Birth:	Email Address:

Ethnicity
(check one only)
	African American (Non-Hispanic)	American Indian or Alaskan Native
	Hispanic/Latino/Latina	White (Non-Hispanic)

On whose taxes were you claimed last year?
(Check one)
Both Parents	Mother	Father
Guardian	Spouse	Self
Other (explain)

Annual Income Levels (2009)

Size of Family Unit Annual Taxable Family Income Must be Below:

1		$16,245
2		$21,855
3		$27,465
4		$33,075
5		$38,685
6		$44,295
7		$49,905
8		$55,515

*For family units with more than 8 members, add the following amount for each additional family member: $5,610 for the 48 contiguous states, the District of Columbia and outlining jurisdiction.

The figures shown under family income represent amounts equal to 150% of the family income levels established by the Census Bureau for determining poverty status. The poverty guidelines were published by the U.S. Department of Health and Human Services in the Federal Register, Vol. 74, No. 14, January 23, 2009, pp. 4199-4201.

Record Release Statement
To help expedite consideration of your application please check the box signifying agreement to the record release statement below: I give permission to the TRiO Student Support Services office to request my admission, financial aid, and academic records in order to obtain t he information necessary to act upon my application, provide services, and generate reports. I am aware that these materials will be kept in my TRiO file and will not be released to anyone else without my permission. I have read, understand, and agree to the above record release statement.
Verification of First Generation College Student Statement
This is to certify that the applicant listed above is eligible for the TRiO program under the first generation provision, since neither parent/guardian completed a bachelor's degree. This statement is true and correct to the best of my knowledge.

Record Release Statement

To help expedite consideration of your application please check the box signifying agreement to the record release statement below:

I give permission to the TRiO Student Support Services office to request my admission, financial aid, and academic records in order to obtain t he information necessary to act upon my application, provide services, and generate reports. I am aware that these materials will be kept in my TRiO file and will not be released to anyone else without my permission.

I have read, understand, and agree to the above record release statement.

Verification of First Generation College Student Statement

This is to certify that the applicant listed above is eligible for the TRiO program under the first generation provision, since neither parent/guardian completed a bachelor's degree. This statement is true and correct to the best of my knowledge.

How did you learn about TRiO?
How are you claiming eligibility? Please check all that apply.
	According to the income levels listed, I am low income.
	Neither my parent nor guardian obtained a bachelor's degree.
	I have a disability. If yes, please answer below: What is your disability and do you require accommodations?