Office use only ELIGIBILITY ASSESSMENT FORM UB ___ (Both FG/LI) ReceivedOffice ____/____/____ use only FG ___ UB ___ Packet Sent ____/____/____ LI ___ FG ___ Returned ____/____/____ Letter:Letter: Yes ___ No ___ 1/3Packet ___ Sent ____/____/____ Yes ___ No ___ 1/3 ___ In D/Base ____/____/____ This form should be completed by the parent(s) or guardian(s) of the student who is applying to Upward Bound. All information is confidential and is used to determine eligibility for Upward Bound. If you have any questions, please call your Upward Bound representative at 1-888-237-1667.

Student: ______SS #: _____-____-_____ Male/Female (circle) (Last Name) (First Name) (Mid. Init.)

Student’s Address: ______(Street or P.O. Box) (City/State) (Zip)

Home Phone #: (207) ______-______Cell #: (207) ______-______DOB: ____/____/____ Age: ______

Student’s E-Mail Address: ______

Parent/Guardian E-Mail Address: ______

High School: ______Current Grade: ______

County (circle): Somerset Androscoggin Franklin Kennebec Oxford Other: ______

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Is this student in DHS custody? ___YES ___ NO (If YES do not fill out the rest of this form. Go to the end, sign, and return to the U.B. office.)

List Names of Every List Every Last Grade Place Number of Hours Wage Total Person Living in the Person’s Completed: of Worked Per Weekly Same House as the Relationship Grade School Employment Per Week Hour Income Student to the Student (GS 1-12) or College (C 1-4)

If one parent (mother or father) is not living in the student’s home, enter that parent’s name and address below.

Mother’s Name: ______Address ______(Street/P.O. Box) (City/State) (Zip)

Father’s Name: ______Address ______(Street/P.O. Box) (City/State) (Zip)

Will Parent/Guardian file a federal income tax return for 2015? YES ___ NO ___ 2015 Taxable Income* here --  $______

*Note: You will find your Taxable Income listed on the following IRS tax forms as: Form 1040 – on Line 43, Form 1040A – on Line 27, or Form 1040EZ – on Line 6. (Other Side) Check (√) all other types of income received by or for any member of the household. Be sure you entered income from work of every person living in your home which you have listed on the front page.

Source of Income √ Source of Income √ Other Social Security a TANF e (Specify by Name) Supplemental Nutrition b Assistance f Child Support Payments Program(SNAP) Soc. Sec. Disability c Income (SSDI) g Alimony Supplementary d Security Income (SSI) h Dividends or Interest

Are you a citizen of the United States? YES____NO ____ If NO, please indicate status and provide documentation ____Legal Alien ____Refugee/Asylee ____Lawful Permanent Resident ____Other, please describe______

Have there been recent changes in your financial situation? YES___ NO ___ If YES, please explain.

______

Do you expect any changes? YES ___ NO ___ If YES, Please Explain.______

______

What is the student’s racial/ethnic background: (optional) (√ all that apply)

___ Black or African American ___ American Indian/Alaskan Native ___ Hispanic

___ Asian ___ Native Hawaiian or Pacific Islander ___ White

Do either of the student’s biological or adoptive parents have a bachelor’s degree or a 4 year college degree?

Yes, Mother ___ Name of College/University ______

Yes, Father ___ Name of College/University ______

No, Neither _____

Does this student have a diagnosed disability? ____ YES ____ NO

If YES, please describe disability: ______

I CERTIFY THAT THE INFORMATION REPORTED ON THIS STATEMENT IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, CORRECT, AND COMPLETE.

______(Parent/Guardian Signature) (Relationship to the Student) (Date)

SEND TO: UMF Upward Bound Web Address: http://upwardbound.umf.maine.edu 238 Main Street, Suite 1 Telephone: (207)778-7297 Farmington, ME 04938 Toll Free: 1-888-237-1667

Non-Discrimination Notice: The University of Maine Farmington does not discriminate on the grounds of race, color, religion, sex, sexual orientation, including transgender status and gender expression, national origin, citizenship status, age, disability, genetic information or veterans status in employment, education, and all other programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Kathleen Falco, Director of Human Resources and Finance, 224 Main St, Farmington, ME 04938, 778-7280 (voice), 778-7000 (TYY/ TDD).