Pa Educational Improvement Tax Credit Scholarship Application printable pdf download

Pa Educational Improvement Tax Credit Scholarship Application

2015/2016

PA Educational Improvement Tax Credit Scholarship Application

Is your child ELIGIBLE?

___Currently attending school in Pennsylvania ___ Do you earn less than $75,000 annually

Scholarship Applying for (choose one) EITC____ OSTC____ Pre-K____

Student’s Information

Student's Full Name: ____________________________________________________________

Last

First

Middle Initial

Gender: [ ] Boy [ ] Girl

Date of Birth ____/____/____

Address:______________________________________________________________________

Street

City

St.

Zip

County

Student School Information:

Present School: ____________________________________________________ Grade: _____

School District: _______________________________ [ ] Public School - [ ] Non-public School

GPA (if applicable)_______

Grade entering September 2015: _____

School you plan to attend with potential Best of the Batch scholarship:_____________________

Annual Tuition (include all required fees):______________

Parent/Guardian Information

1st Parent/Guardian's Name: ________________________________Relationship____________

2nd Parent/Guardian's Name:________________________________Relationship____________

Address:______________________________________________________________________

Email Address__________________________2

Email Address ______________________

Home Phone (___) ___ - _________ Work (___) ___ - _________ Other (___) ___ - _________

Number of people living in my/our household in 2014

: Adults: ___Children: ___

(include yourself)

Current marital status of 1st Parent-Guardian:

[ ] Single [ ] Married [ ] Divorced

[ ] Divorced/Remarried

[ ] Widowed

[ ] Separated-(Mo/Yr)_____

[ ] Other: _________________

Pa Educational Improvement Tax Credit Scholarship Application