Teddy Forstmann Scholarship Program Application Instructions

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1 Application Instructions APPLICATION DEADLINE: FRIDAY, AUGUST 21, 2015,,. Applications postmarked AFTER this deadline may not be awarded. Please be sure to keep in contact regularly with your chosen school to find out your application status. School administrators are available to assist you with any questions or concerns you may have regarding your scholarship application. Ask your child s school to keep copies of all scholarship information in your child s file as well. Application Instructions: Please read through the Instructions carefully. Bring All Completed Forms and Supporting Documents to your chosen school and a school administrator will review and submit the application. Section 1: Print or type your name, address, , and phone numbers. Be sure to include area codes! ONLY THE CHILD/REN APPLYING SHOULD BE INCLUDED IN THE STUDENT INFORMATION. Section 2: Please write the number of persons in your household. Your household includes only those on your 1040 or budget letter. If a child is not claimed on your 1040 tax forms or budget letter, you must provide proof of guardianship (i.e. court papers) and the 1040 tax forms or budget letter from the person claiming the child. List all sources of income. You must report the TOTAL ANNUAL AMOUNT and document all income! If you and your spouse filed taxes jointly, you may list the total amount. Include the income of others that provide support or have claimed the child/ren as dependents. Explanation of Income Sources: Adjusted Gross Income Found on line 37 (1040) or line 21 (1040A). Provide the complete copy of the 1040 tax forms. Any child/ren who are not claimed by the parent applying must send in the income of parent/guardian who claimed the child/ren. If you have Business Income, attach Schedule C or Schedule C-EZ. If the parent/guardian DOES NOT have a 1040, contact the Internal Revenue Service at and request a transcript. Child Support & Alimony Income Provide official court ordered documents citing the amount being received. If child support is not court ordered, a notarized document written by the person providing the support is required. The letter should include the total amount given to the parent and must specify if given yearly, weekly, or monthly. Public Assistance Cash & Food Stamp Income This is found on a budget letter or notice of food stamp benefit. A budget letter is a print out obtained at the public assistance office showing the cash amount and/or coupon the individual is receiving. To obtain a budget letter, please go to your assigned food stamp office, otherwise, you may contact them directly to request one by mail (this service is not available in all offices). To calculate Public Assistance (cash) amount, multiply the grant issued by 24 because it is semi monthly. To calculate Food Stamp (coupon) amount, multiply the coupon amount by 12 because it is monthly. ALL BUDGET LETTERS MUST BE ACCOMPANIED BY A STATEMENT LISTING ALL HOUSEHOLD MEMBERS ON THE CASE. IF SOMEONE IS NOT LISTED ON THE CASE, YOU CANNOT INCLUDE THAT PERSON IN THE HOUSEHOLD. Social Security Untaxed Income This is income that is not reported on your FEDERAL 1040 (line 20b) or 1040A (line 14b). Provide official SSA-1099/SSI letters for all family members receiving SSA Benefits, SSI, and/or Disability. Unemployment & Worker s Compensation Income Unemployment compensation is includible in gross income. You must report unemployment compensation on line 19 of Form 1040, line 13 of Form 1040A, or line 3 of Form 1040EZ. If you do not claim your award on your taxes, you are required to submit the 1099G form (award letter). If you need a copy of your letter, you may visit the New York State Department of Labor website here: and print a copy of your letter. Other Income If you do not file taxes, but work, you must provide a notarized letter from your employer stating your total annual income. If you are receiving assistance from family/friends, you must provide notarized letters written by the person providing the support. The letter must state the annual amount given to you. If you are a FOSTER parent, an official letter from the Aid to Families with Dependent Children-Foster Care Program (AFDC-FC) must be submitted. School Commitment Form: The principal from your chosen school must sign and return the School Commitment Form to our office. It is your responsibility to obtain and keep a copy of the SCF for your records.

2 For Your Information Only NOTE: DO NOT RETURN THIS FORM TO CSF Income Eligibility Scale *Maximum Income Based on Total Annual 2014 Income House size Maximum Eligible Income* Two $42,471 Three $53,433 Four $64,395 Five $75,357 Six $86,319 Seven $97,281 Eight $108,243 For Each Additional Family Member Add $10,962 Note: Please note the scholarship amounts vary depending on the family s income, household size and the school s tuition cost. The highest scholarship amount for will be $2,900. Families will be expected to contribute partial tuition towards their child s education. For additional information about our scholarship guidelines and program eligibility requirements, please visit our website: nyc.scholarshipfund.org Before you return your Application Forms, please check the following: APPLICATION CHECKLIST I filled in all blank spaces that is required information asked for on the Application Form. The number of household members on my Application Form agrees with the number of dependents on my Federal 1040 tax forms and/or Budget Letter. I provided legible documentation verifying my income sources: Complete copy, including all schedules, of my 2014 Federal 1040 tax return and/or the 1040 tax return for the person claiming my child. Public Assistance I provided the Budget Letter including the statement listing the names in the household. Food Stamps I provided the Budget Letter including statement listing the names in the household. Child support or alimony I provided official court ordered or notarized documents. Social Security I provided official SSA-1099/SSI letters for all family receiving benefits. Unemployment Benefits I provided official statement. Worker s Compensation I provided official statement. Other government assistance I provided official statement. Financial aid from family/friends I provided official statements or notarized documents. I completed, signed, and dated the Application Form. I made copies of the Application Form and my income documents to keep for my own records. Failure to complete any of the steps on the Application Form will delay the processing of your application. If you do NOT have all of the documentation required to complete your application, your scholarship will be terminated.

3 Application Information Form Awards will be made on a first-come first-served basis until all funds are exhausted. *** This form does not guarantee a scholarship. Send Completed Forms to: Questions? Call PARENT/GUARDIAN INFORMATION First Name Middle Initial Last Name First Language: English Spanish Other Mailing Address Apartment Number: City State Zip Address (required): Home Phone Work Phone Cell Phone Alternate Phone Marital Status (check one): Single Married Divorced Widowed Legally Separated Employment Status (check one): Full Time Part Time Not Employed Relationship to child/ren (check one): Father Mother Stepparent Grandparent Fosterparent Guardian STUDENT INFORMATION Please provide the following information ONLY for the children for whom you are applying: Child 1 Child 2 Child 3 Child 4 Child s Full Name Child s of Birth Gender: Male or Female Race (optional, check one): Child s Public School Name in Child s Grade Level Hawaiian or Other Hawaiian or Other Hawaiian or Other PLEASE ATTACH THE PUBLIC SCHOOL REPORT CARD FOR EACH CHILD Hawaiian or Other VERIFICATION I certify that all the information provided on this form is true and complete to the best of my knowledge. I promise to pay my child s school account in a timely manner, ensure at least 90% attendance of my child/ren, and comply with the standards of my child/ren s chosen school. I understand that failure to comply with the above statements will result in the loss of my family s scholarship. I agree to allow the school to release grades and standardized test scores for use by CSF, in order to allow CSF to evaluate this program. I agree to allow my child s picture to be taken and used for promotional and fundraising purposes. I agree to submit one photo of my child and one letter from my child to CSF each school year. Finally, I agree to release CSF from any and all liability in its efforts to provide this scholarship. Signature of Applicant

4 Financial Information Form Awards will be made on a first-come first-served basis until all funds are exhausted. *** This form does not guarantee a scholarship. Send Completed Forms to: Questions? Call PARENT/GUARDIAN INFORMATION First Name Middle Initial Last Name Number of people in your household as reported on your 2014 Tax Return or Budget Letter Total Number of Adults: Total Number of Children: 2014 INCOME SOURCE YEARLY ANNUAL AMOUNT For Office Use Only Adjusted Gross Income reported on 2014 FEDERAL 1040 Taxes. Any child/ren that is not claimed by parent applying must send in income of parent/guardian who claimed child/ren. Please refer to line 37 (1040) or line 21 (1040A) (attach your latest 1040 including all schedules) $ Business Income from Self Employment that is not reported on your (provide copies of your business tax return, financial statements and/or other support) $ Child Support Income and/or Alimony Received (provide official court ordered or notarized documents) $ Public Assistance Cash (provide a Budget Letter, include letter listing household members) $ Food Stamp Income (provide a Budget Letter, include letter listing household members) $ Social Security UNTAXED Income that is not reported on your FEDERAL 1040 (line 20b) or 1040A (line 14b) (provide official SSA-1099/SSI letters for all family receiving benefits) $ Unemployment or Worker s Compensation (provide official statement or Form 1099-G) $ Other income such as financial assistance from family or friends (provide official or notarized documents) $ TOTAL HOUSEHOLD INCOME $ If you filed taxes in 2014: Attach a signed copy of your 2014 Federal 1040 tax return including all schedules. Married couples filing separately must attach both forms. Do not send State tax forms or W2 forms. For a free copy of your 1040 call the Internal Revenue Service at You must also attach complete and accurate documentation of any income NOT reported on your 1040 and official documentation for any household members whose names do not appear on your I certify that all the information provided on this form is true and complete to the best of my knowledge. I promise to pay my child s school account in a timely manner, ensure at least 90% attendance of my child/ren, and comply with the standards of my child/ren s chosen school. I understand that failure to comply with the above statements will result in the loss of my family s scholarship. I agree to allow the school to release grades and standardized test scores for use by CSF, in order to allow CSF to evaluate this program. I agree to allow my child s picture to be taken and used for promotional and fundraising purposes. I agree to submit one photo of my child and one letter from my child to CSF each school year. Finally, I agree to release CSF from any and all liability in its efforts to provide this scholarship. Signature of Applicant

5 School Commitment Form This form is to be completed by the Principal ONLY. Please complete this form only after a student has been accepted to your school. Please use one form per student. Return this form to: This form does not guarantee a scholarship. Parents must also complete the Application and Financial Information forms and document their income and household size in order to be eligible for a scholarship. Awards will be made on a first-come, first-serve basis until funds are exhausted. Questions? Call or visit us on the web: School Information: Name of School: School Phone # Address: City: State: Zip: SECTION 1 Student Information: Student Name: Sex: Parent/Guardian Name: Relationship: School attended last year: Tuition Information: Grade in school year (If your school does not use traditional grades, please use K for 5-year-olds, 1st for 6-year-olds, etc.): Tuition for this child (include family discount if applicable, do not include registration, book or activity fees, uniform costs, etc.): $ Amount of financial aid from your school or other source: $ Please check the appropriate box for each statement below. Did the student start school on the first day of the academic year? Yes No If no, enter start date: Does the student and/or family owe any money to your school for tuition or fees? Yes No Was the student enrolled in your school last year? Yes No Was the student enrolled in your Universal Pre-K program during the school year? Yes No n/a TERMS OF AGREEMENT SECTION 2 Our school has accepted this student for enrollment. Our school wishes to participate with the in assisting in the education of the above student. We acknowledge that the s continued payment is strictly contingent upon the family meeting and maintaining conditions of eligibility, and upon the family remaining current on all fees and tuition payments. We agree to monitor the student and report to the about any conditions that would disqualify the family from participation in the Teddy Forstmann Scholarship program. Should any conditions occur that would change the amount of award given to the family or if we believe the family considers leaving the school, we will inform the program. We understand further that the will, in consultation with a participating school, annually review the status and progress of participating students for the purposes of monitoring and verifying their continued eligibility for participation. We agree to provide the student s report card and standardized test scores to CSF and to work with the family to submit a photograph and letter for the child to CSF. Finally, we certify the above information to be correct and agree to the terms outlined. Signature of Principal Print Name of Principal FOR OFFICE USE ONLY! Scholarship Amount: $

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