2016 Local Scholarship Application
*Must attach resume, class schedule, transcript and tax information.
Please note that all information on this form is confidential. The persons serving on the scholarship committees will respect your rights to privacy. This form is for local scholarships only.
Name of Scholarship:
Name:
Address:
Cell phone: Home phone:
Date of Birth: Sex: ____ Male _____ Female
Marital Status _____ Single _____ Married Dependents: ____Yes _____No
Parent/Guardian Information
With whom do you live?
Father/Mother Stepfather/Mother Father/Stepmother
Father Only Mother Only Stepfather Only
Stepmother Only Both Grandparents One Grandparent
Other Relative Foster Parent Other Nonrelative
Please list for those of which you reside.
Mother’s Name: Occupation:
Father’s Name: Occupation:
Stepmother’s Name: Occupation:
Stepfather’s Name: Occupation:
Grandmother’s Name: Occupation:
Grandfather’s Name: Occupation:
Other Guardian Name: Occupation:
Other Guardian Name: Occupation:
Do you have a parent who is deceased?
High school from which parents graduated:
High school from which grandparents graduated:
Is either parent or grandparent a military veteran or on active duty? ____ YES _____NO
If yes, please list the branch of service:
Academic Information
Elementary school attended:
Current class schedule: PLEASE ATTACH
GPA at the end of junior year (PLEASE ATTACH TRANSCRIPT):
Weighted-
Unweighted-
Rank in class after junior year:
Total absences (9th-11th grade):
ACT composite (Best Score):
SAT math (Best Score):
SAT verbal (Best Score):
College/Technical School planning to attend (list in order of preference):
1.
2.
3.
Intended field of study:
List number of persons in your household who currently attend college/technical school:
List number of persons in your household who will be attending college/technical school in the 2016-2017 school year:
1. Write a brief essay about your future occupational plans.
2. Write a brief essay on why you deserve the scholarship (not including financial need).
3. Please explain any hardships/special circumstances in which you feel are important for the consideration of the scholarship committee.
Financial Information
Please note: Many scholarships are awarded based on financial need. If you choose not to include financial information/documents, qualification for some scholarships may be relinquished.
Answer the following questions if you (the student) filed a 2015 tax return. Please attach the first two pages of the 2015 IRS 1040.
1. For 2015, did you (the student) file an IRS tax return? YES NO
2. How much did you (and spouse) receive in social security benefits for 2015?
Answer the following questions about the parents/guardians who are financially responsible for the student. Please attach the first two pages of the parent/guardian’s 2015 IRS 1040.
1. What is the marital status of your parents as of today?
2. How many people live in your household?
3. In 2015, did you, your parents, or anyone in your household receive benefits from any of the federal programs listed? Check all that apply.
______Supplemental Security Income
______Food Stamps
______Medical Card
______TANF
______WIC
4. What income tax return did your parents file for 2015?
______IRS 1040
______IRS 1040A or 1040 EZ
______A foreign tax return
5. What was your parents’ adjusted gross income for 2015?
(Adjusted gross income is on IRS form 1040-line 37; 1040A- line 21; or 1040EZ- line 4)
6. How much did your parents earn from working (wages, salaries, tips, combat pay, etc.) in 2015?
(Answer this question whether or not they filed a tax return. This information may be on your W-2 forms, or on IRS Form-line 7+12+18+14 of IRS Schedule K-1 , Form 1065; 1040A- line 7; or 1040EZ-line 1.)
7. How much did your parents receive in social security benefits for 2015?
8. What was the total amount of child support your parent received in 2015?