Illinois Central College  •   Room 308B  •   1 College Drive •    East Peoria, Illinois 61635-0001  •   (309) 694-8944  •  triosss@icc.edu

Instructions for completing this application:

A. Read and answer carefully.

B. If not already completed, students are required to take the Academic Placement Tests. 

C. Students cannot participate in program activities until all application materials are approved.

D. If you need assistance or request clarification in answering these questions, please call our office at (309) 694-8944, or contact us by e-mail, triosss@icc.edu.

The information you provide will be held in the strictest confidence.
I. General Information:
First Name *
Middle Name *
Last Name *
ICC Student ID # *
Date of Birth *
Social Security Number *
Address *
Address 2:
City *
State: *
Zip Code *
Home Phone *
Cell Phone Number *
ICC Email Address: *
II. Demographic and Academic Information:
Gender (Sex):
Ethnic Background:
Are you a U.S. Citizen? *
If not a U.S. citizen, are are you a permanent resident of a U.S. territory or have you applied, or do you intend to apply for U.S. citizenship?
Follow Up Citizenship Response: *
Do you have a H. S. diploma or GED?
ICC Major:
ICC GPA:
Are you physically challenged or learning disabled?  If yes, please provide documentation.
Disability Inquiry Response: *
If yes, request documentation (e.g., IEP, Access Services, medical, etc.):
Have you applied for financial assistance (FAFSA)?
Are you currently receiving financial assistance (FAFSA)?
Is your tuition being paid by any special programs (e.g., Peoria Promise, ICC Educational Foundation, Workforce Network, etc.)?
If yes, source of tuition?
III. Family and Income Information:
Have either of your parents/ guardians received a bachelors (four-year) degree? *
Total Household Size: *
Family (Household) Taxable Income Range:
Your most recent IRS 1040 form (please mask SS#'s & DOB's):
Parent(s)/Guardian(s) most recent IRS 1040 form (please mask SS#'s & DOB's; Independent students as defined by FAFSA can skip this step):

If you and/or your parents/guardians did not file a tax form, you and/or your parents/guardians should complete the following (otherwise select Non Applicable and continue to Assessment Data section):   

Myself (did not file)
Parent(s) or Guardian(s) (did not file)
Not Applicable (IRS 1040 Forms filed)

I (and/or my parents/guardians) did not file a tax return for the following reason(s) (check all that apply):
Received no taxable income
Taxable income below amount required for filing a tax return (submit copy of W-2's):
Copies of W-2's (mask SS# and submit if box checked above):
Other (Explain):
Explanation (if Other-Explain box checked):
Received non-taxable income from the following source(s): Check all that apply.
Social Security Benefits:
Disability Benefits:
TANF Benefits:
Food Stamps (SNAP/AFDC):
ADC Benefits:
IV. Assessment Data:
How did you hear about the TRiO SSS Program?  Check all that apply.
Admissions/Enrollment Office:
Community Agency:
Friends:
High School Staff:
Upward Bound Staff:
Talent Search Staff:
ICC Instructor/Staff:
TRiO SSS Members:
Student Services Office:
Other:

Sign and Submit:

                          PLEASE READ CAREFULLY BEFORE SIGNING

I certify that any information I have provided is true and correct to the best of my knowledge. I understand that TRiO Student Support Services' staff will use the data provided on this application form to assist in assessing academic needs, and that all of the information will be kept confidential.

I do hereby consent to the release of the following information to the TRiO Student Support Services Program:

1. Information from the Financial Assistance Office concerning my application for an award of financial assistance.

2. All academic records, including the release of pertinent documentation verifying student attendance from any transfer institution, that may assist the TRiO Student Support Services Program in determining my needs and providing essential services.

I also understand that the TRiO Student Support Services staff can assist me in achieving my goals only if I fulfill my obligation, and that failure to meet my responsibilities as required can result in suspension or termination from the program.
Applicant Signature: *
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.
Signature Date: *