Income Verification Form - 2016-2017 Page 2
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2EDCHOICE SCHOLARSHIP PROGRAM
2016-2017 INCOME VERIFICATION FORM
2015 FEDERAL POVERTY GUIDELINES
Source: Federal Register, Vol. 81, No. 15, January 25, 2016, pp. 4036-4037.
EdChoice families qualify for low income status if income is at or
Number in
below 200% of the Federal Poverty Guidelines. This chart will help
Gross Annual Amount (200%)
you determine if you may qualify.
Household
o
Income status determines priority for awarding scholarships.
$23,600
1
It also determines if you family will be responsible for paying
$32,040
2
any tuition that is not covered by the scholarship.
o
$40,320
3
Based on the number of people in your household, if your
gross annual income is the amount listed on the chart or less,
$48,600
4
you may qualify for low income status.
$56,880
5
o
Household size is determined by the following: the scholar-
$65,160
6
ship student, the legal guardian of the scholarship student, the
$73,460
spouse of the legal guardian or birth father of any child under
7
the age of 18 which the legal guardian also has custody.
$81,780
8
o
Based on your household, determine from the list below
For each additional
which one fits your status. For example: If your status is #1
$8,320
AND #4, submit the documents for both.
person add:
You must provide documentation for all sources of income in your household. Documents should representative your CURRENT income.
Please do not send original documents as they cannot be returned to you.
1) If you are currently employed (and have the same job you had all of last year): Send 4 current pay stubs for each job or your W-2s.
2) If you are currently employed (but did not work your current job for all of last year): Send 4 currrent pay stubs for each job.
3) If you are self-employed: Send a copy of your 2015 income tax forms, including Schedule C (the Profit and Loss statement).
4) If you receive other income sources: (eg., food stamps/OWF, child support, unemployment, Social Security, etc.): Send copies of official
documentation that shows how much you receive from each one.
Example: If you currently work and receive food stamps and child support, you need to send in four current pay stubs, official documentation
that shows how much you receive in food stamps, and official documentation that shows how much you receive in child support.
List each person that has earned or unearned income. If someone has more than one source of income, use multiple lines.
Gross Amount
How Often Received
First and Last Name
Name of Employer or Income Source
Before Taxes
Example: John Smith
$1200
Bi-Weekly
Employment-Kroger
Example: Jane Smith
$475
Monthly
Child Support
Signature of Primary Legal Guardian Required
Date
Please copy all documents. Return this form and all income document copies to the address below. NO FAXES ACCEPTED
Ohio Department of Education, Scholarship Program Office
Deadline to submit is July 31, 2016
Deadline to submit is July 31, 2016
25 S. Front Street, Mail Stop 309 Columbus, Ohio 43215
Click here for page 1
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ODE.SSEO.NEO.IncomeVerifForm.1.25.2016
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