Tuition Assistance Form

2017-2018 School Year

As an outreach ministry of Evangelical Lutheran Church of Mt. Horeb, it is Agape Christian Preschool’s intention to make it possible for as many area children to attend our preschool program as possible. Because funds are limited, the criteria for granting financial assistance are based on special need. In order to qualify for financial assistance, a child’s parent(s)/guardian(s) must return a completed financial aid form and page one and two of their most recent 1040 tax form. Incomplete applications will not be considered. Since the amount of financial assistance is limited, Agape Christian Preschool bases its judgment on the relative need expressed in each application. The number of applicants each year also affects the number and amount of financial assistance awarded.

Please print with black or blue ink and all complete all information. Incomplete forms will be returned for completion.

1)  STUDENT/FAMILY INFORMATION

Student Name: Last______First______M.I______

Address: Street______

State______Zip Code______

FATHER/STEPFATHER/GUARDIAN MOTHER/STEPMOTHER/GUARDIAN

Name______Name______

Occupation______Occupation______

Employer______Employer______

Work Phone______Work Phone______

Parent/Guardian Marital Status: Married Single Divorced Widowed

(circle one)

2)  DEPENDENTS (List all dependents including this student)

3) INCOME INFORMATION

A. Parent/Guardian/Student (Combined) Actual 2016 Information

Adjusted Gross Income from IRS Form 1040,

1040A or 1040EZ. This is the last line of page one of the

IRS form. Please attach a copy of page one and two

of your tax form. $______See other side

Alimony and/or Child Support Received $______

Untaxed Income and Benefits (Including

Social Security, AFCD, Untaxed Unemployment

Compensation and/or VA Benefits) $______

Tuition Assistance from other source $______

(Friend, Relative, etc.)

4) Tuition Assistance REQUEST (Must be Completed)

Amount requested for the 2017-2018 school year* $______

*Maximum annual tuition reduction is $535.00 for a two day class and $787.00 for a 3 day class. Additional funding, if available, may be awarded at the discretion of the Preschool. Assistance is awarded on the basis of financial need. If you wish to make Agape Christian Preschool aware of any special circumstances, please feel free to submit any additional information on a separate sheet of paper. Agape Christian Preschool does not discriminate on the basis of race, creed, color or sex.

______

Signature of Father/Stepfather/Guardian Signature of Mother/Stepmother/Guardian

Important: All requested information must be submitted. This form must be complete and a copy of your 2016 income tax form must be submitted for your request to be reviewed and any scholarship to be awarded.

For office use only:

Date Received______Reviewed By______

Amount Awarded for 2017-2018 School Year______

Amount of Tuition Family Pays for 2017-2018 School Year______