2018-2019 Financial Worksheet

PCC Foundation Scholarship Application

Due at time of scholarship deadline (March 1st, 2018 11:59pm)

Directions: Complete the following blanks and save to your computer. Then log into your PCC Foundation Scholarship Application and upload the form. If you cannot fill out the form, please go to the Computer Resource Center for assistance. If you have questions please email .

The following information is used by the PCC Foundation Office in order to determine a student’s economic need. It is required that either a student complete a FAFSA application, or this worksheet, in order to have a complete scholarship application. This information will be kept confidential and will not be used for any reason other than to support the scholarship application.
  1. Student’s Information

Last name, First name MI PCC ID (G#)

PCC Email Address Primary phone number Date of Birth

  1. Family Information(If you were born before January 1, 1995, skip section B)

(Please indicate all monetary values in dollars)

  1. List your parents (step-parents, legal guardians, adoptive parents), and others that your parents financially support. (siblings, dependents, etc.) If you do not have contact with your parents, or would like to further explain any extenuating family circumstances, please attach an additional sheet with your name and statement.

Family member’s name / Relation to student / Age / In College?
Ann Snieder (example) / Mother / 65 / yes

(if you need more room, continue on an additional page)

  1. Indicate your parent’s 2017 income. (If they did not have an income in 2017, indicate zero)

Family member’s name / Employer / 2017 Earned Income
Joe Ruez (example) / Petco / $36,000
  1. Student’s Income Information

(Please indicate all monetary values in dollars)

  1. If you were employed during 2017, list the employer’s name and how much you earned through the year. If you did not work, indicate N/A in the chart. Please include your spouse’s income here as well if you are married.

Employer’s Name / 2017 Amount Earned
Suzy’s Auto Body Shop (example) / $2,000.00
  1. Did you receive financial help from friends or family outside of the United States in 2017?(circle one)

Yes☐No☐

  1. If so how much did you receive?
  1. Did you receive financial support from a sponsor or family member in the United States in 2017?

Yes☐No☐

  1. If so how much did you receive?
  1. Did you receive any other financial support for 2017?

Yes☐No☐

  1. If so list it here
  1. If you have a personal checking/savings account, please indicate the current balance.
  1. Current balance of checking/savings accounts
  1. Student’s Financial Obligations
  1. Indicate below if you financially support anyone other than yourself here in the United States. (children, parents, dependents, etc.)

Full Name / Age / Relation to student
(example) Joey Hannel / 12 / Son
  1. Did you pay child support in 2017?

Yes☐No☐

If yes, indicate how much you paid in 2017.

  1. Did you provide monetary support to anyone outside of the United States in 2017?

Yes☐No☐

If yes, indicate how much you provided in 2017.

If there are any other circumstances related to your finances that you would like to explain, please indicate those here:

  1. Certification and SignatureIf you need assistance with the form:

I certify that all of the information reported on thisPCC Foundation Office

worksheet is complete and correct. The student must , 971-722-4385

sign this worksheetSylvania, CC 114

Student’s SignatureDate