Pa Educational Improvement Tax Credit Scholarship Application (Page 2 of 3) in pdf

Household Income Information

To be eligible for a scholarship, your annual household income (including income from all persons living in the

household and any child support, alimony, public assistance, Supplemental Income - SSI, Disability Income, Social

Security benefits or pensions) must not exceed $75,000. With this application, you must submit a copy of your

Federal Income Tax Return (IRS Form 1040, 1040A, 1040EZ) for the year 2014 with copies of all W-2 Forms and

documentation of all other income sources. Any parent or guardian who claims the student as a dependent must

report income on this form and attach the necessary documentation.

Income Sources:

Gross Income reported on 2014 Federal 1040 Forms

1st Parent-Guardian

2nd Parent-Guardian

Total Household Income

$_____________.___

$______________.___

$_______________.___

Did you complete the FASA Form on-line? ____Yes ___No

Statement Question

In 500 words or less please answer the following question on a separate sheet of paper.

How will you show your commitment to your child’s education this school year?

Verification Signature:

I certify that all of the included information is true and correct, all income is reported and the income

documents enclosed provide a true and accurate verification of my annual household income. I

understand that the deliberate misrepresentation of the information may result in the scholarship being

denied or terminated, and may subject me to prosecution under State and Federal laws. I understand that

the grant payments will continue for one year only as long as my child is enrolled at the school, my

family continues to qualify under the scholarship income guidelines, and I stay current on the tuition

balance. Any unused portion of the scholarship award, for whatever reason, must be refunded to Best of

the Batch Foundation. Further, I understand that the scholarships are awarded according to the prioritized

selection of the qualified applicants, as per the guidelines, and that the grant awards are the sole

responsibility of Best of the Batch Foundation, and all decisions are final. I agree to have my child's past

and current progress reports released by the school to Best of the Batch Foundation for program

evaluation. I give my permission to Best of the Batch Foundation to release the name of my child for

media purposes if he or she is awarded a scholarship. I agree to release Best of the Batch Foundation, and

it is Board of Officers and Directors and employees or partners, from any liability in its efforts to provide

1-year educational grants which are renewable annually at the sole discretion of Best of the Batch

Foundation.

_____________________________________________________________________________

Signature of 1st Parent/Guardian

Social Security #

Date

_____________________________________________________________________________

Signature of 2nd Parent/ Guardian

Social Security #

Date

Office Use Only

Date Received:

Completed: Yes No

By:

Score #1

Score #2

Score #3

Score#4

Score#5

Pa Educational Improvement Tax Credit Scholarship Application Page 2

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