RESOURCE CENTER ASSISTANCE APPLICATION Please clearly print all information on application. Complete the application in blue/black ink. Do not leave any blank spaces enter 0 or N/A if it does not apply. Make sure all required documents are returned with your application. Incomplete applications cannot be processed and will be returned. Section One: Please fill out this section completely. The SID is your CBC Student ID number. Print and attach your class schedule. Checkmark the box(es) next to the assistance you are requesting. If you are requesting childcare assistance, fill out the box on page four. Travel students need to fill out their physical address, and submit a form of correspondence showing student s name at same address. Mail submitted to verify address can be no older than one month. Section Two: Completely fill out the Income Chart. Write the income amount or a 0 in each box. o The first column is for your income information. o Fill out the second column and list the income and amount for the other people in your home. Write in the number of people who live in your household, and/or any persons living outside the home who contribute income to the household. List their names and relationship to you. Section Three: Print out your financial aid information using the Financial Aid Portal in the CBC Kiosk. See instructions in section three of this application. Check box indicating financial aid status. Section Four: Read the statement, sign, date, and print your name at the bottom of the page. 1
Frequently Asked Questions Q: I live with family/roommates/friends, but I pay all of my own bills/split expenses. Do I still need to bring in their income information? A: In order to verify your income status, you will need to have the people who you are living with write and sign a short note stating how bills are being shared and the expense amounts. Q: My mailing address is a P.O. box, so I don t have any letters with my name and home address. What can I turn in to verify my physical address? A: Alternate verification that we ll accept includes a copy of your lease with your name and home address, utilities billing statement, or other form showing your name and home address. A Driver s License will NOT be accepted as proof of address. Q: I m having trouble finding a licensed childcare provider. Where can I go for help? Do I have to wait until I have licensed care to turn in my application? A: You may turn in your application before you have a licensed childcare provider; however, if approved for the program, we cannot provide assistance until you have started using licensed care. If you are having trouble finding a provider, Child Care Aware of Washington (wa.childcareaware.org/families) has an online search tool, or you can call them at 1-800-446-1114. If you have a provider in mind and you want to check their license status, you can use the Child Care Check tool on the website for the Washington State Department of Early Learning (del.wa.gov). You can also call the community help line, 211, for assistance. The Resource Center does not provide referrals. Q: Once I turn in my application, how long will it take to process? A: Applications are typically reviewed within one week. If more information is necessary for your application, this can delay the process. Q: How will I be notified if I am accepted/denied, or if more information is needed? A: We will send an acceptance/denial letter to the email address you have listed on the application. We will call the contact phone number listed on the application if more information is needed. 2
THE RESOURCE CENTER Assistance Application Columbia Basin College 2600 N. 20 th Avenue MS-T7 Pasco, WA 99301 rcdesk@columbiabasin.edu Phone: 509.542.5525 Fax: 509.544.2032 Date Stamp Here Please clearly print all information on the application in blue or black ink. Submitted applications are processed on a first-come/first-served basis. Incomplete applications will be returned. Section 1: Name (please print) SID Mailing Address City State Zip Physical Address City State Zip Home Phone ( ) Cell Phone ( ) Date of Birth Email Emergency Contact Person Phone ( ) Current class schedule is attached REQUESTED ASSISTANCE: Childcare Reimbursement Travel Expense Assistance Distance must be at least 50 miles round trip from CBC. GED Fee Voucher Must either be currently registered in ABE classes, or have completed classes within the last 12 months. Must be Level 4 or above. Night Taxi / Dial-a-Ride Other (explain): FOR STUDENTS REQUESTING TRAVEL ASSISTANCE Verification of my physical address is attached. If I am approved for travel assistance and I move to a new address, I understand I must bring new verification to the Resource Center to continue to be approved for funds. 3
I am carpooling with other students to campus. I understand that only one student per carpool group is allowed to apply for travel reimbursement. Failure to report carpooling status may result in removal from this program and further disciplinary action. Names of students in carpool group: FOR STUDENTS REQUESTING CHILDCARE ASSISTANCE Must use state licensed daycare if approved. Do you receive childcare assistance from any other agency? Failure to report assistance from other agencies, may result in removal from this program and further disciplinary action. If yes, co-pay amount $ Please enter names and ages of children in household: 1. Age: 2. Age: 3. Age: 4. Age: Number of children assistance requested for: Section 2: Income Fill out tables below. Income documents should show the year-to-date income. Please make copies of these forms to attach to your application. For any income type that does not apply, enter a 0 or N/A in the box. Applications cannot be processed until all income verification documentation is submitted and all information is accurately entered below. If self-employed, a bank statement showing your Year-To-Date Income will be accepted as proof of income. Total number of people living in the home: Names of people in household Relationship to applicant Contributes income to household? 4
Section 2: continued Year-To-Date Income Type of Income Student s Income Other s Income Net pay (after taxes): Social Security income: TANF/GAU income: Unemployment income: Alimony/child support: Retirement income: Housing Assistance: Food stamps: Other income (e.g. Financial Aid) Total Income after Taxes $ $ Average Monthly Expenses Type of Expense Paid by Student Paid by Other House payment/rent: Car payment: Electric, phone, etc.: Food: Childcare expense: Child support payment: Auto/insurance: Gas/oil: Loan payments: Other expenses: Total Monthly Expenses $ $ 5
Section 3: Financial Aid Print the Financial Aid Portal, found under your MyCBC Home page. Use your social security number and your six-digit birth date to log in. Check that the Academic Year lists the correct year. Under the section Information We Need From You is a list of paperwork required to complete your financial aid file. Double-check that all paperwork has been turned in. If you have any questions about your financial aid, please speak with Hawk Central. Checkmark below to indicate your current status: Financial Aid information is attached Did not apply Not eligible for Financial Aid (circle one): ABE / ESL / GED / Running Start Other: Section 4: I authorize the release of information from any and all agencies. I will follow the procedures outlined in the approval letter, if I am approved for services. I understand that the Resource Center reserves the right to cancel assistance if procedures are not followed. My signature below confirms that the information provided in this application is correct, and permits the Resource Center to verify ALL information submitted. Applicant Signature: Date: Printed Name: FOR OFFICE USE ONLY APPROVED: RG AHorosky AHamill DENIED Notes: Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and affirmative action. CBC does not discriminate on the basis of race, color, creed, religion, national or ethnic origin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment. Questions or complaints may be referred to Camilla Glatt, Vice President for Human Resources & Legal Affairs and CBC s Title IX Coordinator at (509) 542-5548. Individuals with disabilities are encouraged to participate in all college sponsored events and programs. If you have a disability, and require an accommodation, please contact the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request. 6