Summer Academy in Applied Science and Technology School of Engineering and Applied Science, University of Pennsylvania

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1 Summer Academy in Applied Science and Technology School of Engineering and Applied Science, University of Pennsylvania SUMMER 2015 FINANCIAL AID APPLICATION FORM For US Citizens Please submit a copy of your parents most recent 1040 Tax Forms and W-2 statements (2014). Mail your financial aid form and supporting materials to: ATTN: SAAST Office of Academic Programs School of Engineering and Applied Science 220 South 33 rd St. 111 Towne Building Philadelphia, PA *To expedite the process to saast@seas.upenn.edu or fax to * Section A Applicant Information Name: Last First Middle Home address: Street Social Security #: Telephone: ( ) Date of Birth: City State Zip Code Daytime phone: ( ) Mother ( ) Father address: Fax #: ( ) Section B Family Information Mother s full name: Custodial Non-custodial Father s full name: Custodial Non-custodial Father / Stepmom / Male Guardian (please circle) Mother / Stepmother / Female Guardian (please circle) Employed Self employed Employed Self employed Unemployed Since: Unemployed Since: Occupation: Employer: No. of Years: Telephone: ( ) Occupation: Employer: No. of Years: Telephone: ( ) Are your parents separated or divorced? Yes No

2 Divorced, Separated, or Remarried Parents If the student s natural or adoptive parents are divorced, separated or remarried, please fill out the following: Name of noncustodial parent: Date of Separation: Date of Divorce: Address: City: State: Zip: Phone: Employer/ Occupation: Custodial parent remarried? Yes No If so when? Noncustodial parent remarried? Yes No If so when? Who has claimed the student as a tax deduction? Child Support and Alimony: Received in 2014 Paid in 2014 Child Support for all children $ $ Child support for student applicant $ $ Alimony $ $ List those in your household who will be dependent upon (i.e., supported by) your parent(s) in Include yourself, your parent(s) (or your custodial parent if divorced/ separated), your (step) brothers and (step) sisters, and other relatives. Name Age Check if living with family Name of Present School or Year in School/ Tuition and Fees Room and Board Scholarships or Gift Aid Parental Support Toward Educational Expenses Name of Institution to be Attended Type of Institution Public School Private School Check if Full Time Section C Parental Financial Information Estimated Resources List the amounts you expect to contribute toward your education and living expenses for 2015 from these sources. Do not include anticipated financial aid. From parent(s) income/ assets Child support / non-custodial parent contribution From Student assets Student earnings from summer employment Outside scholarships Grants from parent(s) employer Other (please specify) Total

3 Indicate taxable and/ or non-taxable income received from any of the following sources (estimate) Disability Benefits or Worker s Compensation $ $ Deferred Compensation $ $ Housing/ Living Allowances (clergy, military, etc.) $ $ Pension/ IRA $ $ Social Security: Parents(s) Disability Retirement $ $ Student applicant $ $ Other children (# of children receiving benefit ) $ $ Other (please specify) $ $ Taxes paid in 2014 (if you itemize, refer to your 1040 Schedule A) State and local taxes Real estate taxes Real Estate Owned $ $ Do not include your primary home. Attach additional pages if necessary. Date of purchase Purchase price $ Current value $ Current debt $ Date of purchase Purchase price $ Current value $ Current debt $ Does either parent hold interest in: A. a corporation Yes No B. a partnership Yes No C. a farm Yes No D. a Schedule C Business Yes No If the answer to A is yes, fax ( ) or (saast@seas.upenn.edu) your most recently completed IRS Form 1120 or 1120S, including all schedules and K-1s. If the answer to B is yes, submit your most recently completed IRS form 1065, including all K-1s. If the answer to C or D is yes, submit your most recently completed tax returns, all pages, schedules and W-2 s to SAAST. Name of Business Year Entered Business Current Total Net Value Percent of Ownership Parental Debt Current Amount Owed Monthly Payment # of Remaining Payments First Mortgage $ $ $ Second mortgage/ home equity loan $ $ $ Reason for borrowing Higher Education: $ $ $ For parent(s) education $ $ $ For sibling(s) not currently enrolled (do not include sibling(s) student loans) (name of siblings) Other (please specify) $ $ $

4 Parents Retirement Assets Indicate estimated resources that will be available for parents retirement. List accumulated value for Tax-Deferred Annuities (401K, 403B, etc.), IRA Plans, and other(s) in the space provided. You do not need to list amounts for Social Security, Civil Service/ Military, State, and other pensions. Tax-Deferred annuities (401K, 403B etc.) $ Social Security IRA/ SIMPLE/ SEP plans $ Civil Service/ Military Other (specify) $ State Pension $ Union Pension $ Employer Pension (Optional) We encourage you and your parents to explain any extraordinary financial circumstances that may have a bearing on your financial aid application. You may attach an additional page if necessary (please include your name). Income Worksheet Monthly Annual Total monthly family income net after taxes from all sources: $ $ Plus income tax refund (use annual column) $ $ Other income (Student summer income, parents other income from gifts or family contributions, trust, dividends, inheritance, child support or alimony etc.) $ $ (A) Total annual income $ $ Expenses Mortgage/rent $ $ Utilities $ $ Insurance payments: Auto $ $ Life $ $ Home $ $ Other: $ $ Food $ $ Transportation $ $ Medical (not reimbursed by insurance) $ $ Debt: Auto loan $ $ Home Equity loan (s) $ $ Educational $ $

5 Monthly Annual Other (specify the reason each debt was incurred): Children's expenses: $ $ $ $ Total Expenses. (B) $ $ Total Income Less Total Expenses (A B) = Net surplus or deficit) $ $ Savings Retirement fund contributions $ $ Other: $ $ $ $ Total Savings $ $ Section D Estimated Resources Note: Because funds are limited, we base all awards on financial eligibility. 1. List the amount you can contribute toward the 2015 SAAST program cost of $7,375: From parent(s) income/assets From spouse s income/assets Other Total $ $ Section E Statement of Certification and Understanding We understand that the information provided on this form will be used to determine an estimate of the applicant s financial aid eligibility for SAAST and does not guarantee an official financial aid award. We hereby certify that the information presented on this application is correct at this time. Signature of mother or guardian Date: Signature of father or guardian Date:

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