Highlights Foundation Scholarship Application Form Page 3
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4CONFIDENTIAL
Highlights Foundation Scholarship Application Form
(This information will remain confidential.)
Section A: Yourself
1.
_______________________________________
___________________________________ _______
(Last Name)
(First Name)
(MI)
2.
Your mailing address:
_____________________________________________________________________________________ _
___________________________________
_________________________________ _____________
(City)
(State)
(Zip Code)
3.
Program for which I seek scholarship aid:
__________________________________________________________________________________________
______________________________________________________ __________________________________
(Workshop Title)
(Date)
Section B: Optional
4.
Place of birth: ______________________________
5. Date of birth: __________________________
6.
Ethnic background: __________________________
Section C: Income, Earnings, and Benefits
(Use the most recent tax information you have available.)
7.
The following Federal income tax figures are from ____________ (year).
The form these numbers come from:
❏
❏
a complete IRS Form 1040EZ or 1040A
a complete IRS Form 1040
❏
❏
an estimated IRS Form 1040EZ or 1040A
an estimated IRS Form 1040
❏
a tax turn will not be filed
(Tax Filers Only)
8.
Total number of exemptions
_______________________
9.
Income from IRS Form 1040, 1040A, or 1040EZ
$ _______________________
10. U.S. income tax paid
$ _______________________
11. Income earned from work
(self ) $ _______________________
12. Income earned from work
(spouse) $ _______________________
13. Untaxed income and benefits (yearly totals only)
A. Social Security benefits
$ _______________________
B. Aid to Families with Dependent Children
$ _______________________
C. Child support received for all children
$ _______________________
D. Other untaxed income and benefits
$ _______________________
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