SECU Foundation Scholarship Information

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1 To be considered, the student MUST: SECU Foundation Scholarship Information Be enrolled in a Continuing Education program at Coastal Carolina Community College that leads to a state-regulated or industry recognized credential Be a US Citizen and a North Carolina resident Be in one of the following target groups: unemployment insurance claimant, unemployed, underemployed, member of the NC National Guard, military veteran or spouse of military veteran Complete the application and provide the Human Services Staff with all required documents Consent to the release of their name and image for publications written/distributed by the System Office, Coastal Carolina Community College, and/or the State Employees Credit Union and its Foundation Scholarship funds may be applied to the student s account to pay for registration fees, books, and supplies. Awards are for 750.

2 State Employee Credit Union (SECU) Scholarship Please Note In order for your application to be reviewed and to expedite processing, all required documentation must accompany your completed application when you return it to our office. (109 Continuing Ed Building) *****Only ONE document is required for each eligibility item.***** Date Eligibility Item Verification Documents Accepted Picture ID Residential Address Driver s License or Student ID. (MUST have current legal name on it) Driver s License, Utility Bill, Rent Receipt, Lease, Voter Registration Card, Medicaid Card (MUST show current street address and applicant s name) US Citizenship & Birth Date Birth Certificate, US Passport, Naturalization Certificate Attached Number in Family Verification Form Number in Family (MUST be completed by someone who is at least 18 years old not living in your home or related to you) Income for EVERY working family member is required. Time period Family* Income immediate past year. Military members MUST provide LES s. Last Year Gross** Other employment can be verified with pay stubs or the attached Employer Verification Form Veteran or Spouse of Veteran DD 214 NC National Guard Member Notice of Lay off or Termination Unemployment Compensation Benefits Assessment Receipts Current documents/orders Letter from employer or termination documentation Print Out of Benefits or Award Letter JOURNEY Assessment taken in the Career Center (LRC, room 113) Monday Friday 8:30am 4:30pm Tuition/books/supplies receipts * Family = Spouse & Children under 18 years old living at home and claimed as a dependent on their taxes. ** Gross = Income before taxes. (Includes BAS/BAH for military members) Coastal Carolina Community College 444 Western Boulevard Jacksonville, NC

3 SECU Scholarship Coastal Carolina Community College LAST NAME FIRST NAME MIDDLE INITIAL GENDER DATE of BIRTH STREET/MAILING ADDRESS CITY STATE ZIP COUNTY PRIMARY PHONE SECONDARY PHONE SOCIAL SECURITY # What is your program of study? Have you applied and been accepted to this program? Yes No When does course begin? Date: Are you or your spouse a Veteran? Yes No Are you currently a member of the NC National Guard? Yes No Are you currently employed? Yes No Have you received notice of a layoff? Yes No Are you receiving Unemployment compensation? Yes No List your current or most recent Job. Job Title Hourly Wage Company Name Start Date End Date Hours Worked Per Week Address/Phone Reason for Leaving Job Duties I have applied for: WIA Scholarship Golden Leaf I am currently receiving or have been approved to receive: WIA Scholarship Golden Leaf If you currently receive or been approved for any benefits from the following, please indicate the amount of assistance below. Food Stamps per month Unemployment per month Veterans Assistance per month Child Support per month Cash Assistance per month Other (i.e. Reserves) per month SSI per month What was your family s total gross income for the past six months? (IF MILITARY YOU MUST INCLUDE HOUSING AND OTHER MILITARY ALLOWANCES!)

4 Write a brief statement explaining your need for financial assistance and why you believe you should receive assistance from the State Employees Credit Union Scholarship? What are your plans and goals after you graduate? Are you a director, employee or family member of an employee of the State Employees Credit Union or SECU Foundation? I certify that the facts listed on this form are true and accurate to the best of my knowledge. Signature Date

5 444 Western Boulevard Jacksonville, North Carolina Phone (910) NUMBER IN FAMILY VERIFICATION I HEREBY AUTHORIZE THE RELEASE OF THIS INFORMATION. Applicant s Signature Date I,, am personally acquainted with the family of: Applicant s Name Address ( ) City State Zip Code Phone To my knowledge, the following people live at the above address: HOUSEHOLD MEMBERS RELATIONSHIP TO APPLICANT Does more than one family live at the above address? Yes No If yes, please explain: ( ) Name of Person Making Verification Relation to Applicant Date Phone Address City State Zip Code *Person making verification must be at least 18 years old and not related to the applicant An Equal Opportunity Institution

6 Return To: INCOME VERIFICATION FORM PLEASE RETURN WITHIN FIVE (5) DAYS TO WHOM IT MAY CONCERN: THIS IS TO VERIFY THAT IS OR HAS BEEN EMPLOYED BY THIS COMPANY, WITH EARNINGS FOR THE LAST 12 MONTHS. PERIOD VERIFIED: AS FOLLOWS: MONTH & YEAR GROSS EARNINGS Signed by verifying person: Date: Company Name: Address: City, State, Zip Code: Telephone Number: ( ) I,, HEREBY AUTHORIZE THE RELEASE OF THIS INFORMATION. Participant s Signature: Date:

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