Scholrship Appliction Prt 1. Plyers enrolled in NB Ajx Soccer Club seeking scholrship. Nmes (First, Middle Initil, Lst) & Tem (Exmple: 96 Girls White or SNAP(formerly food stmp U17) progrm), TANF, CHIPS/Medicid cse# for children only. Skip to Prt 3 if you listed cse#. Prt 2. Totl Household Gross Income-You must tell us how much nd how often A. Nme (List everyone ctully B. Gross income nd how often it ws received C. Check living in household, including Exmple: S100/monthly SlOO/twice month S100/every Circle if children) other week $loo/weekly NO 1. Ernings 2. Welfre,child 3. Socil 4. All Other income from work support, Security, Income before limony pensions, deductions retirement. before deductions ----.i ----.i ----.i ----.i 0 ----.i ----.i ----.i ----.i ----.i ----.i ----.i ----.i ----.i ----.i ----.i ----.i s ----.i s ----.i $ ----.i s ----.i ----.i_ ----.i ----.i ----.i $ S S $ / / / / 3/25/2012, Pge 1 of 2
Prt 3. Signture Scholrship Appliction / nd Socil Security Number (Adult must sign) / / / I An dult household member must sign this form. I certify tht ll informtion on this form is true nd tht ll income is reported. I understnd tht NB Ajx Scholrship Committee Members my verify the informtion. I understnd tht if I purposely give flse informtion, Sign here: X Dte: the plyer my lose the scholrship. Print nme: 0 Don't fill out this prt. This is for officil use only. Annul Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12 Totl Income: Per: Week, Every 2 Weeks, Twice A Month, Month, Yer Household size: Initil Eligibility Determintion Met: Tier I -- Tier2 -- I Did Not Meet: I Reson: Eligibility: Scholrship Awrded or Scholrship Denied Scholrship Committee Members Signture: I Dte: Notes: 3/25/2012 Pge 2 of 2
-,e\.vj~a., I Scholrship Income Eligibility Guidelines Income EligibilityGuidelines s of June 1, 2012 to My 31,2013 Household Federl Tier 2: Qulifies for Federl Progrms t 185% of Tier 1: Qulifies for Federl Progrms t 130% of the Size Poverty the Poverty LeveI Poverty Level Guidelines Annul Annul Monthly Twice Every Weekly Annul Monthly Twice Every Weekly per Two Per Two Month Weeks Month Weeks 1 11,170 20,665 1,723 862 795 398 14,521 1,211 606 559 280 2 15,130 27,991 2,333 1,167 1,077 539 19,669 1,640 820 757 379 3 19,090 35,317 2,944 1,472 1,359 680 24,817 2,069 1,035 955 478 4 23,050 42,643 3,554 1,777 1,641 821 29,965 2,498 1,249 1,153 577 5 27,010 49,969 4,165 2,083 1,922 961 35,113 2,927 1,464 1,351 676 6 30,970 57,295 4,775 2,388 2,204 1,102 40,261 3,356 1,678 1,549 775 7 34,930 64,621 5,386 2,693 2,486 1,243 45,409 3,785 1,893 1,747 874 8 38,890 71,947 5,996 2,998 2,768 1,384 50,557 4,214 2,107 1,945 973 For ech 3,960 7,326 611 306 282 141 5,148 429 215 198 99 dditionl fmily member dd
Determining Household Income Reportble Income Income to be reported on the eligible household's ppliction for scholrship is ny money received on recurring bsis including gross erned income. Specificlly, gross income mens ll money erned before such deductions s income txes, employee's Socil Security txes, insurnce premiums nd bonds. Income includes:./ Pyment of money for services; including wges, slry, tips, commissions or fees../ Socil Security benefits../ Supplementl Security Income (551)../ Public ssistnce/welfre pyments (TANF, etc.), but not SNAP benefits../ Alimony or child support pyments../ Unemployment compenstion../ Government civilin employee or militry retirement or pension../ Vetern's pyments../ Privte pension, nuities or retirement income../ Regulr contributions from persons not living in the household../ Strike benefits../ Workers' compenstion or disbility benefits../ Net income for self-employed frmers nd businesspersons, net rentl income nd roylties../ Dividends or interest on svings or bonds../ Income from esttes or trusts../ Other csh income, including csh mounts received or withdrwn from svings, investments../ Trust ccounts nd other resources tht would be vilble to py the price of child's mel../ Militry benefits received in csh, such s housing llownces for militry households living off bse nd food llownces../ Adoption ssistnce pyments under Title XIX-E of Socil Security (medicl ssistnce). Current Income Households must report current income the ppliction. Current income mens income is bsed on the most recent informtion vilble. This my be for the current month; the mount projected for the first month the ppliction is mde for or for the month prior to the ppliction. If this income is higher or lower thn usul nd does not firly or ccurtely represent the household's ctul circumstnces, the household my project its nnul rte of income bsed on the following guidelines:./ Sesonl Workers nd Others Sesonl workers nd others whose income fluctutes usully ern more money in some months thn in other months. Consequently, the previous month's income will commonly distort the household's ctul circumstnces. In these situtions, the household my project its nnul rte of income nd report this mount s its current income. If the prior yer's income provides n ccurte reflection of the household's current nnul rte of income, the prior yer my be used s bsis for the projected nnul rte of income../ Grnished Wges nd Bnkruptcy Income is the gross income received by household before deductions. In the cse of grnished wges nd income ordered to be used in specified mnner, the totl gross income must be considered regrdless of whtever portions 11
Determining Household Income re grnisheed or used to py creditors. A common exmple of grnisheed wges includes limony nd child support pyments.../ Self-employment Income Self-employed persons my use lst yer's income s bse to project their current yer's net income, unless their current monthly income provides more ccurte mesure. Self-employed persons re credited with net income rther thn gross income s described here. Net income for self-employment is figured by subtrcting business expenses from gross receipts. o Gross receipts include the totl vlue of goods sold or services rendered by the business. o Deductible business expenses include cost of goods purchsed, rent, het, utilities, deprecition chrges, wges nd slries pid nd business txes (not personl federl, stte, or locl income txes). For household with income from wges nd self-employment, ech mount must be listed seprtely. When there is business loss, income from wges my not be reduced by the mount of the business loss. If income from selfemployment is negtive, it should be listed s zero income.../ Frm Income Net income for self-employed frmers is figured by subtrcting the frmer's operting expenses from the gross receipts. o Gross receipts include the vlue of ll products sold; money received from the rentl of frmlnd, buildings or equipment to others; nd incidentl receipts from the sle of items such s wood, snd nd grvel. o A frmer's operting expenses include cost of feed, fertilizers, seed, nd other frming supplies; csh wges pid to frmhnds; deprecition chrges; csh rent; interest on frm mortgges; frm building repirs; nd frm txes (but not stte nd federl income txes).../ Militry Income/Benefits Militry benefits received in csh, such s housing llownces for militry households living off bse nd food llownces, must be considered s income. However, the vlue of in-kind benefits other thn csh, such s on-bse housing, is not considered s income. The housing llownce for militry personnel living in privtized housing will not be counted s income. Only the portion of the deployed service member's income mde vilble by the service member, or on their behlf, to the household where the children re stying should be counted s income. Deployment Extension Incentive Py (DEIP) is given to ctive-duty service members who gree to extend their militry service by completing deployment with their units without re-enlisting. This extension pplies only until the service members return to their home sttion. Any dditionl DEIP pyments provided to service members serving t their home sttion is considered income s they re no longer considered deployed. Do not count ny mounts listed s Combt Py s household income. Combt py is lso referred to by the u.s. Deprtment of Defense s "Hostile Fire Py/Imminent Dnger Py" (HFP/IDP). The entry on the militry Leve nd Ernings Sttements (LES) is "HFPjIDP" nd my not sy "combt py", however they should be treted eqully.../ Income for Foster Children In determining income for the foster child, only the following should be considered: o Welfre funds tht re identified by ctegory for shelter nd cre nd those identified s specil needs funds, such s those for medicl nd therpeutic needs, re not considered s income. Where welfre funds cnnot be identified by ctegory, no portions of the provided funds re considered s income. o Other funds received by the child. This includes, but is not limited to, monies provided by the child's fmily for personl use nd ernings from employment other thn occsionl or prt-time jobs.
Determining Household Income v' Alimony nd Child Support Any monies received by household in the form of limony or child support re counted s income. Any monies pid out for limony or child support my not be deducted from household's reported gross income. v' Lump Sum Pyments Lump sum pyments or lrge csh settlements re not counted s income since they re not received on regulr bsis. These funds my be provided s compenstion for loss tht must be replced, such s pyment from n insurnce compny for fire dmge to house. When lump sum pyments re put into svings ccount nd the household regulrly drws from tht ccount for living expenses, the mount withdrwn is counted s income. Income Exclusions Income not to be reported or counted s income in the determintion of household's eligibility for free nd reducedprice benefits includes: Any csh income or vlue of benefits household receives from ny federl progrm tht excludes such income by legisltive prohibition, such s the vlue of benefits provided under the SNAP. Student finncil ssistnce provided for the costs of ttendnce t n eductionl institution, such s grnts nd scholrships, wrded to meet eductionl expenses nd not vilble to py for mels. Lons, such s bnk lons, since these funds re only temporrily vilble nd must be re-pid. The vlue of in-kind compenstion, such s militry on-bse housing or ny other non-csh benefit. Occsionl ernings received on n irregulr bsis, e.g., not recurring, such s pyment for occsionl bbysitting or mowing lwns. Any subsidy household receives through the prescription drug crd progrm. Militry benefits received in csh: s prt of the Fmily Subsistence Supplementl Allownce (FSSA). Pyments mde under the Ntionl Flood Insurnce Progrm for flood mitigtion ctivities to the owner of the property. Rebtes provided to fmilies through the Economic Stimulus Act of 2008 re considered one-time lump sum pyments. Combt Py - Combt py is n dditionl pyment tht is received by militry service members who re deployed, trnsferred or ordered to serve in combt zone. Combt py is received: o In ddition to the service member's bsic py; o As result of the service member's deployment, trnsfer to, or service in n re tht hs been designted s combt zone*; nd o Only while they re deployed to, trnsferred to, or serving in designted combt zone. To Compute Annullncom~ Every Week Multiply the totl gross income by 52 Every Two Weeks Multiply the totl gross income by 26 Twice Month Multiply the totl gross income by 24 Monthly Multiply the totl gross income by 12