EOC intake - Larry

2023- 2024 Confidential Intake Form

This Educational Opportunity Center (EOC) is sponsored by the Community College of Denver. The information requested below is required for federal reporting purposes and will be kept confidential.

The EOC is a non-profit program 100% funded through the U.S. Department of Education and does not discriminate on the basis of race, color, national origin, sex, age, or disability in admission or access to its educational programs

Appointment Date

Name*

First Name

Last Name

Email*

Phone number (Cell Preferred)*

Permission to send a text to your cell phone?*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Dependency- If you are under 24, you are considered dependent for financial aid purposes (unless you have a qualifying circumstance)*

Independent - Older than 23 or Born before Jan 1 2001 Dependent - Younger than 23 years old or Born after Jan 1 2001 I have a qualifying circumstance (independent)

Birth Date - Month Day Year*

Gender - Assigned at Birth*

Female Male Prefer Not to Say

Marital Status*

U.S. Citizenship / Residency *

If Permanent Resident or Eligible Non-Citizen (enter alien number)*

Are you a veteran or connected through Family to the Military? *

Yes No

Please Indicate Which Applies *

Ethnicity*

Hispanic / Latino Non-Hispanic or Latino

Race - Check all that apply

American Indian/Alaska Native Asian Black/African American Caucasian (White) Native Hawaiian or Pacific Islander

Have you graduated High School or Have a GED?*

What High School or GED program are you attending?*

Please indicate your previous college experience (if any)*

Please indicate college attending and student ID*

If you already have completed a college program - indicate if you have a: *

Certificate Associate Degree Bachelor Degree I don't have any of the above

I have applied for Financial Aid in the past (including scholarship, loans and or grants)

yes No

The college I am considering attending is*

What is your intended Major or Program of Study?

Request for EOC services (check the types of services you are seeking)*

Academic Advising College Admission GED information / resources Career Exploration / Planning Financial Aid / Loans / Scholarship Veteran Services

Do you have a child and / or dependent under 18?*

Yes No

Including you, how many household members are supported by your income*

1 2 3 4 5 6 7 8 or more

Including you, how many household members are supported by your income *

1 2 3 4 5 6 7 8 or more

Including you and your spouse, how many household members are supported by both your incomes*

2 3 4 5 6 7 8 or more

How many household members are supported by you and your parents income (include you and your parent(s) in the household size *

2 3 4 5 6 7 8 or more

Was your household's taxable income last year less than $22,590? This amount is also found on line 15 of your 1040 tax form.*

Was your household's taxable income last year less than $30,660? This amount is also found on line 15 of your 1040 tax form.*

Was your household's taxable income last year less than $38,730? This amount is also found on line 15 of your 1040 tax form.*

Was your household's taxable income last year less than $46,800? This amount is also found on line 15 of your 1040 tax form.*

Was your household's taxable income last year less than $54,870? This amount is also found on line 15 of your 1040 tax form.*

Was your household's taxable income last year less than $62,940? This amount is also found on line 15 of your 1040 tax form.*

Was your household's taxable income last year less than $71,010? This amount is also found on line 15 of your 1040 tax form.*

Was your household's taxable income last year less than $79,080? This amount is also found on line 15 of your 1040 tax form.*

If household Taxable income unknown / not sure, please estimate your total household income last year*

For reference, your taxable income is less than total wages earned (adjusted gross)! Take your total income and subtract the amount below to find your taxable income:

Subtract $12,550 from your total income if you filed SINGLE or MARRIED FILING SEPARATELY
Subtract $25,100 from your total income if you filed MARRIED
Subtract $18,800 from your total income if you filed HEAD of HOUSEHOLD

Please change your response to the question above if necessary!

As of September 1st, have you applied for Financial Aid*

Yes No

As of September 1st, have you applied for Admissions at a College and / or University?*

Yes No

Please list school and your school ID

Do either of your natural or adoptive parents have a 4-year university / college degree?*

Yes No

Are you currently participating in any of the following services? (select all that apply)*

Talent Search Upward Bound GEAR UP Student Support Services I did not participate in the above programs

I understand that the above information will be used for statistical and follow-up purposes only. I hereby authorize any agency, school, college or university to release any academic/financial aid information from my files that are requested by the Denver Educational Opportunity Center. I certify that the annual taxable income for last year is as indicated above. My signature below indicates that the information I have provided in this document is accurate and verifiable*

[clear]

Use your mouse or finger to draw your signature above

If Parent Present at the current moment, Please click yes

Yes No

Parent's email Address (if known)

Parent's email address

If you are dependent for financial aid purposes, meaning you are under 24 and do not have a qualifying extenuating circumstance, please have parent sign *

[clear]

Use your mouse or finger to draw your signature above

If you are dependent for financial aid purposes, meaning you are under 24 and do not have a qualifying extenuating circumstance, please forward this form on to one of your parent to complete certification of household income

https://communitycollegeofdenver-xlkis.formstack.com/forms/parent_income_statement