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 Cyndi's
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2011 GFA SCHOLARSHIP - FINANCIAL INFORMATION
Applicant Name ____________________________________________________
Part II - Financial data to be completed by parent or guardian. Please take the
information from your completed 2009 IRS income tax return (1040, 1040A, or
1040EX) or preferably from your 2010 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, 2010 (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 2010-2011 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) know-
ledge. 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.
Signatures:
Applicant _________________
Parent/Guardian ___________________
Date __________________
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