Edward T. Conroy & Jean B. Cryor Memorial Scholarship Program

Transcription

1 OFFICE OF STUDENT FINANCIAL AID Cllege Park, MD TEL: TERP (8377) FAX: Edward T. Cnry & Jean B. Cryr Memrial Schlarship Prgram Purpse: The Edward T. Cnry and Jean B. Cryr Memrial Schlarship Prgram is designed t prvide financial assistance t sns and daughters f deceased, missing in actin r prisner f war United States armed frces persnnel, sns and daughters f deceased public safety persnnel, surviving spuses (wh have nt remarried) f deceased public safety persnnel, disabled public safety persnnel and sns, daughters and/r surviving spuses f victims f the September 11, 2001 terrrist attacks, attending a Maryland pstsecndary institutin. T be cnsidered fr the Edward T. Cnry Memrial Schlarship at the University f Maryland, Cllege Park, students must: Applicatin must be received by July 15, 2018 Be a Maryland resident (with the exceptin f children f a State r lcal public safety emplyee wh died in the line f duty) Applicatins may be mailed t: Attn: Schlarship Selectin Cmmittee Office f Student Financial Aid University f Maryland Cllege Park, MD Or Faxed t: Attn: Schlarship Selectin Cmmittee Renewal Students: Renewal awardees are nt required t reapply each year. The Edward T. Cnry Memrial Schlarship may be renewed n an annual basis fr up t five years f full- time study r eight years f part-time study (r a cmbinatin f bth) prvided there recipient: Is enrlled at least part-time Cntinues t meet all ther eligibility requirements

2 OFFICE OF STUDENT FINANCIAL AID Cllege Park, MD TEL: TERP (8377) FAX: Edward T. Cnry & Jean B. Cryr Memrial Schlarship Applicatin SECTION A - Applicant Infrmatin: (Please Print) 1. UMD UID : - - Date f birth: / / 2. Last name: First name: MI: Previus name under which recrds may bekept: 3. Permanent mailing address: City: State: Zip cde: 4. Hme phne: Wrk phne: 5. address: 6. Are yu a Maryland resident: Yes N If yu are a dependent student, are yur parent(s) Maryland resident(s)? Yes N 7. Have yu applied fr this schlarship in the past? Yes N 8. Has smene else in yur family received this schlarship Yes N 9. Name(s) f persn(s) in yur family wh has/have received this schlarship: 10. Are yu eligible fr the prgram because yu are a sn, daughter, stepchild r surviving spuse f a victim f the September 11, 2001 terrrist attacks (deceased died as a result f the attacks n the Wrld Trade Center, the Pentagn r the crash f United Airlines Flight #93)? Yes N SECTION B - Current Cllege/University Infrmatin: 1. Cmplete name f the Maryland institutin yu will attend in academic year: 2. Degree sught: Undergraduate Graduate Anticipated date f graduatin: / / 3. In Fall semester 2018, I will enrll fr: (please put a numeric amunt in the space prvided belw) # f credits full-time (12+ credits per semester fr undergraduate; 9+credits per semester fr graduate student) # f credits part-time (6-11 credits per semester fr undergraduate; 6-8 credits per semester fr graduate student) 4. In Spring semester 2019, I will enrll fr: # f credits full-time (12+ credits per semester fr undergraduate; 9+ credits per semester fr graduate student) # f credits part-time (6-11 credits per semester fr undergraduate; 6-8 credits per semester fr graduate student)

3 SECTION C - Family Infrmatin: The fllwing infrmatin pertains t the family member wh was killed as a result f military service in the United States armed frces; r, as a result f service as a State r lcal public safety emplyee r vlunteer; r wh suffered a service cnnected 100% permanent disability as a result f military service; r, was a victim f the September 11, 2001 terrrist attacks. 1. Last fur (4) digits f Scial Security Number f persn killed r disabled: _ 2. Last name f persn killed r disabled: First name: MI: 3. Relatinship f applicant t persn killed r disabled: 4. Branch f United States armed frces r name f public safety facility in which persn killed r disabled served, if applicable: 5. Date f: death r disability: / / 6. Address at date f death/disability: City: State: Zip cde: 7. Are yu eligible fr the prgram because yu r yur parent was a POW/MIA f the Vietnam Cnflict? Yes N 8. Are yu currently receiving any ther student financial aid funds because yu are the child r spuse f a victim f the September 11, 2001 terrrist attack? Yes N If yes, please list schlarship name(s) and amunt(s): $ $ SECTION D (If applicable): In the case f 100 percent disabled r deceased military persnnel, and in the case f 25 percent (r mre) disabled military persnnel, please address the fllwing questins. Using a separate sheet f paper, explain the circumstances f the death r disability, the cause, and why it is cnsidered service cnnected. SECTION E - Pledge t Remain Drug Free and Certificatin: As a cnditin f receiving a Maryland State schlarship r grant, I pledge t remain drug free fr the full term f the award. Unlawful use f drugs and alchl may endanger my enrllment in a Maryland cllege as well as my Maryland financial aid award. I certify that the infrmatin given n this frm is true and cmplete t the best f my knwledge. Signature f applicant Date

4 Sectin F- Infrmatin Release Authrizatin Disabled applicant/parent must sign the fllwing authrizatin statement: I,, d hereby cnsent t the release f the requested infrmatin by (Print full name f disabled persn) the Veterans' Administratin r the State r lcal public safety persnnel ffice t the Office f Student Financial Assistance. Disabled persn's signature Date AGENCY CERTIFICATION SECTION G - T be cmpleted by the Veterans' Administratin r the State r lcal public safety persnnel ffice. In the case f 100 percent disabled military persnnel: has a 100 percent* disability rating, and his/her diagnstic cdes are: (Name f disabled persn) Cde(s): Percentage(s): *Veterans must be classified as 100% disabled (i.e., cannt be 90% disabled, but 100% unemplyable). In the case f 25 percent (r mre) disabled military persnnel: has a 25 percent (r mre) disability rating, and his/her diagnstic cdes are: (Name f disabled persn) Cde(s): Percentage(s): This persn has exhausted his/her federal veterans educatinal benefits. This persn is n lnger eligible fr federal veterans educatinal benefits. In the case f deceased r 100 percent disabled public safety emplyees r vlunteers: Please briefly explain hw the death r disability f was classified as a result f State r lcal public safety service: (Name f decreased r disabled) This ffice is unable t prvide the requested infrmatin.

5 FOR OFFICE USE ONLY I hereby certify that the infrmatin prvided n this applicatin is crrect and cntained in ur recrds. Print name f authrized fficial Title Address Signature Phne City State Zip cde Date SECTION H - Required Dcumentatin N applicatin will be cnsidered withut the fllwing materials: Cmpleted applicatin fr the academic year. Make sure yu have cmpleted all necessary sectins. Cpy f yur birth certificate shwing names f bth parents if yu are the sn r daughter f a deceased r 100 percent disabled military persn, POW/MIA f the Vietnam Cnflict, deceased public safety emplyee r vlunteer, r deceased victim f the September 11, 2001 terrrist attacks. Cpies may be btained frm the State Department f Vital Recrds. Cpy f yur marriage certificate (if spuse f deceased public safety emplyee r vlunteer r f deceased victim f the September 11, 2001 terrrist attacks). Cpy f death certificate. Verificatin that yu are 25 percent disabled frm a service cnnected disability as a result f military service and have exhausted r are n lnger eligible fr federal veterans educatinal benefits. (Sectin G required.) Verificatin that death as a result f military service, r that death r 100 percent disability was in the line f duty fr a public safety emplyee r vlunteer. (Sectin C and Sectin G required.) Verificatin that 100 percent disability was frm a service cnnected disability as a result f military service. (Sectin C and Sectin G required. Nte: A cpy f the disabled veteran s award letter may be filed instead f Sectin G). NOTE: D nt send riginal certificate(s); they cannt be returned. Initial applicants are awarded based upn the pstmarked date a cmplete applicatin was received. NOTE: Awards are subject t the availability f funds. Applicatin must be received by July 15, 2018 at: Office f Student Financial Aid Attn: Schlarship Selectin Cmmittee University f Maryland Cllege Park, MD Fax: sfa-schlarships@umd.edu