TRIO - Application Form

TRIO Student Support Services

Application Form
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Student ID number*
MSU address (Minot address during school)*
Permanent home address*
City, State, Zip*
Phone number*
Email address*
example@example.com
Citizenship:*

U.S. CitizenPermanent ResidentNot a U.S. CitizenOther
Gender:*

MaleFemale
Veteran:*

YesNo
Type a question*

SingleMarriedOther
Date

MonthDayYear
Date
Expected Graduation Date*
Educational Goals*

Bachelor DegreeMaster DegreeDoctorate Degree
Major*
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoNo response or Unknown
Race*

American Indian or Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or other Pacific IslanderNo response or Unknown
Are you receiving assistance paying for college? Please check all that apply*

Financial Aid GrantsFinancial Aid LoansWork-studyVeteran’s BenefitsVoc Rehab or other agency fundingScholarshipsEmployer Tuition AssistanceFamily or other financial sponsorship
High School Grade Point Average*
(please estimate if necessary)
ACT or SAT Composite Scores*
(please estimate if necessary)
Where did you attend high school?
Do you have a GED?*

YesNo
Are you a transfer student?*

NoYes
If Yes, where did you transfer from?
Do you have documentation of a disability? (Disabilities include, but are not limited to: ADHD, asthma, CP, diabetes, depression, anxiety, Tourette's, hearing impairment, MS, PTSD, etc.)*

YesNo
Will you be requesting accommodations under the American Disabilities Act?*

YesNo
Highest level of education completed by your Father: (Applicable if you regularly resided with and received support from this parent or legal guardian during your K thru 12 education)

Grade SchoolHigh SchoolGEDSome CollegeAssociate’s DegreeBachelor’s DegreeAdvanced or Professional Degree
Highest level of education completed by your Mother: (Applicable if you regularly resided with and received support from this parent or legal guardian during your K thru 12 education)

Grade SchoolHigh SchoolGEDSome CollegeAssociate’s DegreeBachelor’s DegreeAdvanced or Professional Degree
Financial Aid Status: What is your family size, as reported on your most recent Federal Financial Aid Application?*
Does your taxable income fall within the category for your family size on the following table?*

YesNo

Eligibility Table effective January 15, 2025 until further notice

Family Size	48 Contiguous States, D.C., and Outlying Jurisdictions	Alaska	Hawaii
1	$0 - $23,475	$29,325	$26,985
2	$0 - $31,725	$39,645	$36,480
3	$0 - $39,975	$49,965	$45,975
4	$0 - $48,225	$60,285	$55,470
5	$0 - $56,475	$70,605	$64,965
6	$0 - $64,725	$80,925	$74,460
7	$0 - $72,975	$91,245	$83,955
8	$0 - $81,225	$101,565	$93,450

**For family units with more than eight members, add the following amount for each additional family member: $5,500 for the 48 contiguous states, DC and outlying jurisdictions; $6,880 for Alaska; and $6,330 for Hawaii.

Your TAXABLE income can be found on line 15 of the 2023 form 1040, or line 15 of the 2024 form 1040. Taxable income is typically less than Adjusted Gross Income, which is reported on a FAFSA, because of deductions. Please contact the TRiO-SSS office or submit a copy of your tax form along with this application if applicable.

Please check the services/areas where you have or may have a need for academic assistance*

Learning Skills DevelopmentTutorial AssistanceAdvisingOther
Learning Skills Development

ReadingWritingMathNote takingTest takingStudy skills
Tutorial Assistance

MathScienceOther
Advising

Academic Success PlanningCareerFinancial AidGraduate School AdmissionMentoring/SSS Co-AdvisingPersonalPre-registration schedule planning
Other

Basic Computer Skills InstructionGraduate School PreparationEmergency Health / Family Referral
I certify that the information written on this application is true and correct to the best of my knowledge. With this application I authorize TRIO Student Support Services to obtain from Minot State University’s Financial Aid Office, Registrar's Office and Disability Services Office, all financial, academic and disability related documentation/ records pertinent to my eligibility and participation in TRIO Student Support Services. I further authorize the TRIO Student Support Services program to access enrollment and degree information from the National Student Clearinghouse for retention and graduation data required by the U.S. Department of Education. I understand that the program only serves a limited number of students, acceptance is not guaranteed and my name may be placed on a waiting list until an opening becomes available.
Date

MonthDayYear
Date
Signature*

Clear
How did you hear about TRIO Student Support Services?
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TRIO Student Support Services