Scholarship Application Template (Page 2 of 2) in pdf

CONFIDENTIAL

FINANCIAL INCOME

Gross monthly income of parents: $_____________________.

(Please provide some proof of this income

amount such as last year’s first page of your 1040 with the Social Security numbers crossed out.)

Stated amount is based on: last year’s income expected income during next 3 months

(Include work earnings, welfare payments, child support, pension, retirement, Social Security, dividends, etc.)

Please indicate if you are receiving assistance from any public entity.

(Check all those that apply and provide

requested information.)

 Public Aid

Source: _____________________________ AFDC Case #______________________

 Food Stamps

Food Stamp #________________________ Case # ___________________________

 Free School Lunch  Reduced School Lunch

 Other (Please list) ____________________________________________________________________

Indicate those who are currently unemployed: Father Mother Student

For those marked above, indicate any that are currently receiving unemployment benefits. ___________________

OTHER COMMITMENTS

Please indicate if any of the following apply:

Yes No This student attends a private school. If yes, list school: _____________________________

Yes No This student has his/her own cell phone.

Yes No This student receives lessons or participates in other organizations or activities that require

payment of fees. If so, please list them below.

(Do not include mandatory school registration fees.)

ACTIVITY

AMOUNT PAID FOR ACTIVITY

___________________________________________

$_____________________________

___________________________________________

$_____________________________

VERIFICATION AND SIGNATURE

I/We, the undersigned, being the parent(s) or guardian(s) of the above-listed child do hereby certify that

information provided is true and correct and that I/we are not able to financially contribute the amount

requested above for my/our son or daughter to be able to participate in the program listed above. I/we will

also provide, if requested, income information to verify this fact.

I/We will also provide substantial volunteer help above and beyond the norm for this production.

_____________________________________________

________________________________

Signature of Father or Guardian

Date

_____________________________________________

________________________________

Signature of Mother or Guardian

Date

ADULT CONTACT INFORMATION FOR SCHOLARSHIP RESULTS:

Phone No.: _____________________________________

Father Mother Guardian Student

Email for Adult Contact: _____________________________________________________________

Scholarship Application Template Page 2

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