First Name, Middle Initial

NAME:

LAST NAME

STUDENT NAME

FIRST NAME, MIDDLE INITIAL

APPLICATION INSTRUCTIONS

Applicants must read and follow these instructions carefully. The following criteria must be satisfied in order to be considered for a scholarship to be awarded by the Woodbridge Rotary Scholarship Foundation, Inc.:

1. Applicants must be fulltime residents of Woodbridge Township, New Jersey, since March 1, 2016.

1. Applicants must possess a high school diploma or the equivalent at the time the scholarship is awarded. Applicants do not have to be graduates of the Woodbridge Township high schools.

1. Applicants must be pursuing a posthigh school fulltime course of study at an accredited college, university, trade school, or other educational institution.

1. Applicants must submit, or arrange for the delivery of, the following information by April 17, 2017:

1. The attached application completed in full, including appropriate signatures.

1. A copy (single sided only) of the applicant's and parents’ most recent Federal income tax returns,including all applicableSchedules.

1. A copy of the applicant's most recent school transcript.

1. Applicant must arrange for a character reference from a school official (teacher, guidance counselor, principal, etc.). The school official should send the reference directly to the Scholarship Foundation and must state that the contents of the reference were not disclosed to the applicant. References which do not so indicate will be deemed to have been seen by the applicant.

1. On a separate typewritten sheet (single sided only), please explain your goals and why you feel you should be awarded a scholarship.

All material submitted in connection with an application for a scholarship becomes the property of the Woodbridge Rotary Scholarship Foundation, Inc. and will not be returned. All applications and supporting information will be kept confidential. All scholarships will be awarded without regard to an applicant's race, creed, religion, or color. All decisions regarding scholarships are in the sole discretion of the Woodbridge Rotary Scholarship Foundation, Inc. and are final.

THE FOUNDATION WILL NOT CONSIDER ANY APPLICATION THAT DOES NOT CONTAIN ALL THE INFORMATION REQUIRED.

Certification: All of the information on this form and the Supplemental information, if completed, is true and complete to the best of my knowledge. I realize that if I do not give proof when asked, the student may be denied aid. I understand that if any of the information contained in this application is false, I may be disqualified from consideration for a Scholarship. If I am awarded a Scholarship and it subsequently is discovered that any information contained herein is false, fraudulent, or willfully erroneous, I may be required to repay all monies received from the Woodbridge Rotary Scholarship Foundation, Inc.

Everyone giving information on this form must sign below.

______

STUDENT'S SIGNATURE

______

FATHER'S SIGNATUREMOTHER'S SIGNATURE

Date this form was completed: ______Month ______Day ______Year

STUDENT'S IDENTIFICATION INFORMATION

1.Your name

LastFirstMiddle Initial

2.Your permanent mailing address (Mail will be sent to this address.) Years at this address

Number, Street, Apartment Number

( )

City, State, Zip CodeHome Telephone

Email Address

3.Your social security number 4. Your date of birth

4.School presently attending

5.a.For those applicants who are high school seniors:

Current Class Rank: S.A.T. Scores: Verbal: Math: Writing:

b.For those applicants who are attending a college or university:

Cumulative GPA: Year in school currently completing (circle one): 1 2 3 4 Graduate

6.Are you a resident of Woodbridge Township, NJ? Yes No

If so, date you began living in Woodbridge Township

7.Have you previously received a scholarship from the Woodbridge Rotary Scholarship Foundation, Inc.?

Yes NoWhen?Amount?

STUDENT STATUS

8.For school year 2017-18, please list all scholarships and grants that you havereceived or have been awarded oranticipate receiving for the school year 2017-18. Indicate sources and amounts and which items you have been notified you will receive. If you have not applied for any and do not anticipate applying for any, please so indicate.

For those applicants currently attending a college or university, did you receive any of the following during the 2016-2017 school year: Pell Grant, any school grants or scholarships, and/or private foundation grants? If so, state amount and source. If you did not, please write “none”.

9.List all colleges or schools that you have attended since high school. Always list first the college or school most recently attended.

PERIOD OF ATTENDANCE

FROM TO

NAME OF COLLEGE OR SCHOOL(month/year)(month/year)

10.a.If you know, at this time, please provide the name of the school you will be attending in the fall of 2017and the itemized costs for tuition and room and board for the year.

b.If you do not know, at this time, what school you will be attending in the fall of 2017, please list all schools you have applied to or will apply to. Please indicate which schools you have been accepted at. Additionally, please list itemized estimated costs for tuition and room and board.

SCHOOL / CHECK IF
ACCEPTED / ANNUAL
TUITION / ANNUAL
ROOM AND BOARD

11.Your expected enrollment status during the 2017-18 school year (Check only one.)

Fulltime At least halftime but less than fulltimeLess than halftime

HOUSEHOLD INFORMATION(If you receive more than onehalf of your support from your parents, please indicate the following:)

FAMILY MEMBERS' LISTING Give information for all family members other than yourself.

12.

Full name of family member
(other than applicant) / Age / Relation-
ship (Use
code
below.) / Will attend college at
least half-time in
2017-18 school year?
Yes No / Name of school or college
this person will attend
in 2017-18
school year / Year in
school
2017-18 / Occupation/Employer of this person / If attended same school in
2016-2017, give amount of:
2016-2017
Scholarships/
Grants / 2016-2017
Parents'
Contribution



Write in the correct code from the right.1=Student's parent3=Student's brother or sister5=Student's son or daughter 7=0ther (Explain) in

2=Student's stepparent 4 =Student's husband or wife6 =Student's grandparent"Explanations/Special

Circumstances"

2015 INCOME, EARNINGS, AND BENEFITS

13.Student's Present Occupation/Employer

Employer's Address

Will you continue to work for this employer during the 2017-18 school year? YesNo

TAX FILERS ONLY: PARENTS STUDENT

14.2016income from:

a.Wages, salaries, and tips$$

b.Interest and dividend income$$

c.Net income (or loss) from business as shown on Schedule C.

If a loss, enter the amount in (parentheses).$$

d.Net income (or loss) from real estate or other investments

as shown on Schedule E.$$

e.Alimony received$$

15.2016 untaxed income and benefits (yearly totals only)

Social Security benefits $$

Aid to Families with Dependent Children (AFDC or ADC)$$

Child support received for all children $$

Other untaxed 2016 income and benefits$$

MUST SUPPLY COPIES OF PARENTS' & APPLICANT'S 2016 1040 US TAX RETURNS,

INCLUDING ALL APPLICABLE SCHEDULES.

SUPPLEMENTAL INFORMATION

ASSET INFORMATION

PARENTSSTUDENT

What is it worth today? What is owed on it? What is it worth today? What is owed on it?

16.Cash, savings, and

checking accounts $$

17.Marketable securities, i.e.,

stocks, bonds & mutual funds$$

18. IRA, 401(k), 403(b), and

other retirement plans$$

19. 529 college savings plans$$

20.Home (Renterswrite in "0") $$$$

21.Real estateinvestments $$$$

22.Businessinterests $$$$

PARENTS’ OTHER INFORMATION

23.Parents' monthly home mortgage payment or rent$

24.Have you or your parents made any gifts or transfers to family members or trusts in excess of $1000 during the past 24 months?

YesNo If "Yes," explain in "EXPLANATIONS/SPECIAL CIRCUMSTANCES.”

EXPLANATIONS/SPECIAL CIRCUMSTANCES

25.Use this space to explain any unusual expenses, educational and other debts, or special circumstances.

EXTRACURRICULAR ACTIVITIES

26.List extracurricular activities

MISCELLANEOUS

27.Have you ever been convicted of a crime? Yes No

If so, please provide details.

28.On a separate typewritten sheet (single sided only), please explain your goals and why you feel you should be awarded a scholarship.

WOODBRIDGE ROTARY SCHOLARSHIP FOUNDATION, INC.

P. 0. Box 201  Woodbridge, New Jersey 07095

CHECKLIST OF ITEMS

Completed Application

Applicant’s and Parents’ Federal Income Tax Return, including all applicable Schedules

School Transcript

Written Statement Explaining Goals and Reason Scholarship should be Awarded to Applicant

Arrange for Character Reference

ALL OF THE ABOVE ITEMS ARE REQUIRED TO HAVE A COMPLETED APPLICATION, AND ONLY A COMPLETED APPLICATION WILL BE CONSIDERED.

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