Applicant Name ____________________________________________________
Part II - Financial data to be completed by parent or guardian. Please take the information from your completed 2010 IRS income tax return (1040, 1040A, or 1040EX) or preferably from your 2011 return, if it is completed.
A. Adjusted gross income $ ___________
B. Total US tax paid $ __________
C. Income earned from work by: Father $ ___________ Mother $ ___________
D. Non-taxable income: Social Security, Child support, Welfare, Tax-exempt interest, Veteran's benefits, etc. ___________
E. Medical/Dental expenses not paid by insurance ________
F. Total number of exemptions ___________
G. Total savings and investments at December 31, 2011 (cash, savings and checking accounts, stocks, bonds, mutual funds, CD's, etc.) ___________
H. Applicant's parents' marital status is _____ married_______ single________ separated_____ divorced_______ widowed_______
I. Total of family members who will be attending post-secondary school at least half-time during -2012-2013 school year (include applicant) __________
Part III - Certification and Signatures Certification: All of the information on this form is true and complete to the best of my (our) knowledge. If asked by an authorized official, I (we) agree to provide proof of the information I (we) have given on this form. I (we) realize that this proof may include a certified copy of my (our) U. S. Income Tax Return. I (we) also realize that if I (we) do not provide such proof if asked, the applicant may not receive scholarship aid.
