Verification Information
Employed?
No Yes – Where ________________________________________________________
Check the amount below which best matches your current household’s level of taxable income: (To select an amount,
please refer to tax forms 1040EZ-line 6, 1040A-line 26, or 1040-line 43 ** leave bank if unknown**)
0 – $17,655 $17,656 – $23,895 $23,896 – $30,135
$30,136 – $36,375 $36,376 – $42,615 $42,616 – $48,855
$48,856 – $55,095 $55,096 – $61,335 Over $61,335
Total number in your household:
Disability:
Do you have any type of disability (ex. physical, medical, psychological, learning, attention deficit) or were you
ever in a special education program while in school?
Yes No
Are you aware we have a Disability Services office in the Shephard Center on the third floor?
Yes No
I certify that the above information is true and correct to the best of my knowledge. In addition,
everything mentioned in this application packet—(all forms) are verified by this signature. I hereby
authorize Student Support Services to obtain all academic and financial information necessary to
determine my eligibility.
Applicant Signature: Date:
OCCC is an equal opportunity/affirmative action institution.
OFFICE USE ONLY: Date Application Received:___________
Eligibility requirements met: First Generation / Income / Disability
Student Accepted Yes No Date:______________ Staff Initials____________
Reason Accepted_________________________________________________ APR #