2011 Financial Statement Form Page 2
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2Applicant’s Name_________________________________________________________
4. 2010 Untaxed income and benefits (yearly totals only):
$
Social Security Benefits – include disability, food stamps, etc
$
Child Support received for all children
5. Money in cash, savings and checking accounts:
$
Student
$
Parent(s)
6. Your parent(s) current marital status:
Single
Married
Separated
Widowed
Divorced
7. Number in your parent(s)’ household in 2010-2011
8. Number of college students in household in 2010-2011
WE CERTIFY THAT THE INFORMATION PROVIDED IS ACCURATE:
_________________________________________
____________
Signature of student
Date
______________________________
____________
Signature of parent or legal guardian
Date
After typing this information on the Online Application, bring this document with you for
the March 15 meeting or mail this with your transcript/s to:
Project SEED
P.O. Box 47333
Indianapolis, IN 46247
Attach an official high school transcript & mail together with this form!
2011 Project SEED / Indiana A.C.S. Summer Research Program
Financial Statement Form
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