FATHER FRANCIS T. DIETZ, S.J. SCHOLARSHIP APPLICATION FORM Grades 7 & 8 (Gesu Junior High) Grades 9-12 (Area Catholic High Schools)

Transcription

1 FATHER FRANCIS T. DIETZ, S.J. SCHOLARSHIP APPLICATION FORM Grades 7 & 8 (Gesu Junior High) Grades 9-12 (Area Catholic High Schools) APPLICATION NUMBER (For office use only) DATE OF APPLICATION (Applicant) Please note: All information requested on this form must be completed before an application can be reviewed. Delays caused by returning this form to the applicant because not all information is given, might eliminate the applicant from further consideration. ATTACH COPIES OF THE FIRST TWO PAGES OF THE APPROPRIATE 1040 OR OTHER FEDERAL INCOME TAX FORM FOR PARENTS (OR GUARDIAN) for ALSO INCLUDE A COPY OF YOUR W-2 AND/OR FORM If any income or loss is reported for business income, also attach a copy of Schedule C. If any income or loss is reported for rents, royalties, trusts, etc., attach a copy of Schedule E. If no federal forms were filed for 2015, indicate that on an attachment with the reason for not filing. Please complete ALL items on this form. PRINT information and return the form and attachments to Sr. Kathleen Flannery, O.S.U. at the Gesu Parish Office by MAY 31, ) Applicant s Name Phone 2) Applicant s Age Present School Grade Level ( ) School Applicant will attend in ) Applicant s Address Street City Zip Code 4) How long have you lived at the above address? Years 5) Parents (if one or the other is deceased, please indicate) or guardian(s): Father Mother Single Married Separated Divorced Widowed Applicant lives with Guardian(s) (if applicable)

2 Dietz Scholarship Form-2016/2017 Page 2 Name 6) List ALL other children in the family besides the applicant: Name Age Name of School (if attending) Tuition & Fees Please list any scholarships or financial aid received for any of the other children in your family: 7) Employment: a) Father or Guardian: Occupation: Full time or part time: If part time, how many hours per week? Employer s name: Address: b) Mother or Guardian: Occupation: Full time or part time: If part time, how many hours per week? Employer s name: Address: c) Applicant: Job: Hours per week: Employer s Name & Address Summer job or work during school year: Earnings to date in 2016: Projected earnings for Summer 2016:

3 Dietz Scholarship Form-2016/2017 Page 3 Name 8) Has there been a substantial change in employment, income, or marital status during the last twelve months that has resulted in a significant change in the family s economic position from that shown on the attached income tax forms? If YES, please use the space below to explain. Is there any substantial change expected during the school year? 9) Family Resources: a) Monthly mortgage payment or monthly rent: $ b) Year home purchased: Purchase Price: $ c) List cars: d.) Government Assistance (if on any type of government assistance, indicate the type(s) and the annual amount received): Type(s) $ e.) Assistance from other sources (child support, spousal support, parents, relatives, etc.). Indicate the type(s) and the annual amount received: Type(s) $ f.) Personal family savings: $ g.) Income from other than employment (interest, rent, dividends, etc.): $ 10) Add any additional information relating to the necessity for you to apply for the Dietz Scholarship in the space below. (This might include extraordinary medical expenses, college tuition, changing family, or work status, etc.)

4 Dietz Scholarship Form-2016/2017 Page 4 Name 11) In your opinion, how much of this child s tuition can the family afford? Please state a specific amount: $ 12) What will be your contribution to our Church collections this year? $ 13) Please list all other scholarship or financial assistance for which the applicant or the family has applied to defray the cost of the applicant s education. This would include PSAS/Diocesan Tuition Assistance, CEET, and Castele. 14) ATTACH a copy of the applicant s most recent grade report. 15) Please use the space below for any other information that you believe would help the Dietz Scholarship Committee in determining the applicant s need for assistance. Especially note any forms of service to the Church, School, or Gesu Community.

5 Dietz Scholarship Form-2016/2017 Page 5 Name DO NOT LEAVE THESE ITEMS BLANK Refer to your copy of your 2015 tax return for help in completing this form. Long Form (1040) Short Form (1040A) Did not file 1) Number of full-time working parents/guardians in home: 1) 2) Total exemptions claimed in 2015 OR number of family members living at home, if did not file: 2) 3a) Father s or male guardian s income for year: 3a) Employed: Full-Time Part-Time Unemployed 3b) Mother s or female guardian s income for year: 3b) Employed: Full-Time Part-Time Unemployed 4) Amount of Adjusted Gross Income (Line 21 of Form 1040A, 4) or Line 37 of Form 1040): 5) Amount of money from social security, child support, Veteran s benefits, welfare: 5) 6) ADD items 4 and 5: 6) 7) Enter amount of monthly rent or house payment: 7) Check if you: ( ) Own home ( ) Live with relatives ( ) Rent 8) Multiply item 7 by the number 12 for yearly rent or yearly house payment: 8) 9) Subtract item 8 from item 6 for net income: 9) IN SIGNING THIS APPLICATION, I certify that the above answers are true and correct to the best of my knowledge and belief. Signed: Father Mother Guardian Applicant Do not write in space below: Date application received: Decision: Date of Action: Pastor s Signature