A retired employee or past employee who was employed full-time by a governmental entity in Broward County continuously for at least five years.

Transcription

1 SCHOLARSHIP APPLICATION RALPH H. AND RUTH FRANK GROSS MEMORIAL SCHOLARSHIP Ralph and Ruth Frank Grss understd the value f a gd educatin. This schlarship was established in memry f them and is intended t encurage peple t imprve themselves as well as t prvide fr the betterment f their children. Gvernmental wrkers and their families were selected as qualified recipients because f the many gd deeds that are perfrmed that g unrecgnized. This schlarship is fr cllege, university r vcatinal educatin. The award range is: $500 $2,500 per student. TO BE ELIGIBLE, APPLICANTS MUST: Demnstrate financial need and must nt receive any ther schlarship r grant. Be a resident f the State f Flrida. If applicant is a graduating high schl student, he r she must have an SAT scre f 1100 r higher (CR + MA) and submit fficial high schl transcripts. Plan t attend a cllege, university r vcatinal institute lcated in the State f Flrida either n a full r part-time basis. Graduate students are nt eligible t apply. Agree nt t use tbacc prducts, illegal drugs r abuse alchl fr the duratin f this award. Agree nt t becme a member f a scial srrity f fraternity fr the duratin f this award. Membership f an hnrary, academic, r prfessinal srrity r fraternity is allwed. If emplyer has a tuitin reimbursement prgram, yu may nt be eligible fr this award. See page 4 f this applicatin. APPLICANT MUST ALSO BE ONE OF THE FOLLOWING: (Please check nly ne categry that describes yu best) A current full-time emplyee f a gvernmental entity in Brward Cunty. A retired emplyee r past emplyee wh was emplyed full-time by a gvernmental entity in Brward Cunty cntinuusly fr at least five years. A past emplyee wh was disabled as a result f a perfrmance f his/her functins f emplyment while emplyed fulltime fr at least five years at a gvernmental entity in Brward Cunty. A spuse, frmer spuse r child f an emplyee wh currently is emplyed full-time at a gvernmental entity in Brward Cunty r an emplyee wh meets ne f the requirements abve r wh was killed in the line f duty while emplyed full-time fr at least five years at a gvernmental entity in Brward Cunty. Check the fllwing that applies t yu: Spuse Frmer Spuse Child Year f marriage Year f Marriage (Must be married at least 5 years) Year f Divrce (Must have been married at least 5 years) Yu can dwnlad this applicatin at cfbrward.rg/schlarships

2 APPLICATION CHECKLIST This cmpleted applicatin with prper signatures. Yur 2016 tax return r the Student Aid Reprt (SAR) yu received after filing yur 2017 FAFSA. If yu are a high schl student, yur 2016 tax return (if yu filed) and yur parent s/legal guardian s 2016 tax return. If yu are an adult, yur 2016 tax return Prf f Flrida Residency. (Fr prf f residency yu must submit a cpy f yur r yur parent s/guardian s driver's license r a cpy f an identificatin card that was issued mre than a year f applicatin date.) If yu are a high schl student, yu must include an fficial high schl transcript. Typed essay n yur persnal educatinal interests and gals. If yu are an adult currently attending cllege, yu must include the mst recent fficial transcript. If yu are an adult wh is planning t return r attend cllege fr the first time, yu must submit prf f enrllment. Cpy f yur SAT r ACT scres, r ther applicable testing results. Signed Emplyee Verificatin Frm (page 4) l YOUR APPLICATION WILL NOT BE CONSIDERED IF THERE ARE ANY MISSING ATTACHMENTS. Mail applicatin and all attachments t: Cmmunity Fundatin f Brward Ralph H. and Ruth Frank Grss Memrial Schlarship 910 East Las Olas Bulevard, Suite 200 Frt Lauderdale, FL (954) Please DO NOT fax r applicatin Yu can dwnlad this applicatin at cfbrward.rg/schlarships If yu have questins, please cntact: Amanda Kah, Charitable Funds Manager, at ext. 115 r akah@cfbrward.rg

3 I. APPLICANT Name: Telephne: Last First M.I. Street City Zip Date f Birth: MM/DD/YYYY Cuntry f Birth: Are yu a brn U.S. citizen? If n, are yu a naturalized U.S. citizen? Yes N Yes N Gender: Male Female Other Scial Security Number: Please check the ne that applies t yu: Current graduating high schl senir Adult Gvernment Emplyee s Name (if different frm applicant s name): II. PARENT(S) OR GUARDIAN Prvide the name, address and phne number f the parent(s) r guardian yu reside with. Name: Last First Name(s) Street City Zip Telephne: (Area Cde) Relatinship t Student: (Parents, Mther, Father, Aunt, Uncle, Grandparent, etc.) Student has been a Brward resident fr at least 1 year? YES NO Date Flrida residency began fr Parent/Guardian III. EDUCATION Name f High Schl Graduatin Date: Mnth Year If yu are a graduating high schl senir, please prvide yur SAT and/r ACT scres. SAT: Critical Reading Math Ttal ACT: English Math Reading Science Cmpsite

4 Name f pst-secndary schl yu plan t attend during the schl year. If unknwn, list schl(s) yu applied t: Lcatin: Accepted Applied 1 st Chice City State Lcatin: Accepted Applied 2 nd Chice City State 4 yr. Cllege r University Cmmunity Cllege Vcatinal Schl Other Enrllment status (if applicable): Full-time Part-time Living Arrangements: On campus Off campus Cmmute frm hme Number f credit hurs yu plan n taking each semester: Fall 2017 Spring/ Summer 2018 Majr r curse f study: IV. ESSAY On a separate piece f paper, please prvide a ne-sided, ne-page nly typed essay describing yur persnal educatinal interests and future gals. V. FINANCE Yu must submit the fllwing finance dcumentatin with yur applicatin: If yu are a high schl student, yu must include a cpy f yur incme tax return (nly if yu filed) and a cpy f yur parent s r legal guardian s incme tax return fr the 2016 tax year (IRS-Frm 1040). Yu must include the W-2 s. If yu r yur parent/guardian has nt yet filed an incme tax return fr 2016, yu may submit the previus year s return, with an explanatin f any substantial changes. If fr any reasn yur parent/guardian is nt required t file an IRS-Frm 1040, yu must include a cpy f yur/their W-2 Frm fr If yu are an adult, yur 2016 tax return. OR The Student Aid Reprt (SAR) yu received after filing yur 2017 Free Applicatin fr Federal Student Aid (FAFSA). VI. CERTIFICATION AND SIGNATURE I hereby affirm that the infrmatin prvided is true and cmplete t the best f my knwledge. If asked by an authrized fficial, I agree t give prf f the infrmatin that I have given n this frm. Falsificatin f infrmatin may result in my ineligibility fr this schlarship and terminatin f any schlarship granted. This applicatin becmes the prperty f the Cmmunity Fundatin f Brward. Applicant s Signature Date

5 EMPLOYEE VERIFICATION FORM The applicant named belw is applying fr a schlarship administered by the Cmmunity Fundatin f Brward. Yur emplyee verificatin is needed as part f the applicatin prcess. This frm must be signed by the Human Resurce Directr f the Gvernment Entity f the emplyee. The applicatin deadline is April 24, This is t verify that (Type r print emplyee s full name) falls int ne f the fllwing categries: Please check the categry which best describes the emplyee: Current full-time emplyee f a gvernmental entity in Brward Cunty. Retired emplyee f a gvernmental entity in Brward Cunty wh was emplyed full-time fr at least 10 cnsecutive years. Previus full-time emplyee f a gvernmental entity in Brward Cunty fr at least five cnsecutive years, r wh was disabled as a result f perfrmance f his/her functins f emplyment. Tuitin Reimbursement Prgram (Please check the apprpriate bx) Emplyee is currently receiving a tuitin reimbursement. Emplyee is NOT eligible fr reimbursement under ur current tuitin reimbursement prgram. Emplyee is NOT eligible fr reimbursement fr dependents. Entity des nt currently have a tuitin reimbursement prgram. Cmments: Name f Gvernment Entity where abve was/is emplyed: Date f hire fr this emplyee: City: State: Zip: Phne: I hereby affirm that the abve infrmatin is true and accurate t the best f my knwledge. Directr f Human Resurce Dept. (please print) Date Signature f Directr f Human Resurce Dept. Phne (in case f questins)