If you have received the Single Parent Scholarship Fund of Van Buren County continuously for consecutive scholarship terms, you may reapply for our scholarship using this Renewal Scholarship Application. PURPOSE This fund was established in 1996 under the auspices of the Arkansas Single Parent Scholarship Fund to encourage single parents to continue their education. The fund provides supplemental financial assistance to recipients residing in Van Buren County, Arkansas, who are pursuing a course of instruction which will improve their income-earning potential. Scholarships may be used for tuition, books, utility bills, car maintenance, child care, etc. ELIGIBILITY CRITERIA Applicants who are renewing a scholarship will continue to follow the guidelines under which you entered our program, as long as you are continuously awarded each spring and fall. REQUIREMENTS: The following documents need to be submitted in addition to the attached application form: 1. Proof of enrollment - Class schedule for upcoming term or registrar verification. If a class schedule is not available at the time of your application, you may submit verification from the registrar with your application. However, a class schedule must still be provided before your scholarship is awarded. 2. Proof of income - Tax return (first page of most recent year). If you are exempt from filing a tax return, submit a Proof of Income statement from the Department of Human Services. Other income verification may be considered if these documents do not apply to your situation. 3. Pell Grant (FAFSA) copy of your Student Aid Report (SAR), or letter from your school s Financial Aid Office that states your approval or denial for financial aid during the term for which this scholarship is to be used. If you did not apply for FAFSA, provide an explanation. 4. Current transcript - An unofficial copy of your transcript showing your most recent grades, with cumulative GPA. You may download or print this from your school's website. DEADLINES: Fall Semester: June 15 (priority consideration), July 15, September 15 Spring Semester: December 1 Summer Semester: May 15 Updated 04/05/2018 Page 1 of 6
Complete your application using pen or computer only. What semester are you applying for? What year? FALL June 15 Priority consideration, July 15, September 15 SPRING Deadline December 1 SUMMER Deadline May 15 1. Name Social Security # 2. Mailing Address Street or PO Box City Zip 3. Residential Address Physical Address City Zip 4. Phone: (Home) (Work) (Cell) 5. A message phone where you can receive messages within 24 hours: 6. E-mail address: (Primary) (Alternate) 7. How long have you been a resident of Van Buren County? 8. Age: Date of Birth / / 9. Gender: Male Female 10. Race: for reporting purposes only has no effect on your eligibility for this scholarship Black Asian Hispanic Native American Caucasian Other 11. Marital Status: *You'll be asked to explain your circumstances and may be asked for additional documentation. Never married / single Widowed Divorced Legally separated* Married but living apart* 12. Including you, how many individuals are dependent on you for financial help or support? List them below. Name of Child/Dependent Living with you? (Y/N) Gender (M/F) Age Date of Birth School Grade, if applicable Updated 04/05/2018 Page 2 of 6
HOUSEHOLD & FINANCIAL INFORMATION 13. I am the head of the household: YES NO 14. Contact information of your nearest relative who will always know where/how to reach you: Name: Relationship: Phone: Address: Number and Street Apartment # City State ZIP Code 15. Is anyone sharing your household expenses with you? YES NO 16. Will you be working for income while you go to school? YES. Name of your employer Hours per week: NO 17. What was your total income and expense for the last 12 months. a. Total Income $ b. Total Expenses $ c. Subtract expense from income. What is the difference? $ d. If expenses are greater than income, please explain how you make up the difference: 18. Financial Aid and Other Support: FAFSA (Pell & Loans) WIA / NADC Grant (Workforce Investment Act / North Arkansas Development Center Grant) Go Opportunities Grant (Arkansas Lottery Scholarship) Career Pathways Have you applied for this? (Y/N) If you have been granted this, what amount will you receive per semester? Updated 04/05/2018 Page 3 of 6
19. Have you previously applied for an Arkansas Single Parent Scholarship? YES NO If yes, were you awarded a scholarship? YES NO If awarded for the semester you are applying, what do you plan to use your scholarship for? 20. Have there been any changes in your situation since you first applied for this scholarship (i.e. changes in family, finances, educational goals, etc.)? Use the space below or attach a separate page to describe the changes in your circumstances. Updated 04/05/2018 Page 4 of 6
EDUCATIONAL INFORMATION 21. What school do you attend? 22. What is your program of study (major)? 23. When did you begin this program (start date)? 24. When do you expect to graduate or complete this program (month and year)? 25. What is your cumulative grade point average? 26. How many hours do you plan to attend during the semester in which this scholarship is used? Will you be a full-time or part-time student? FULL PART TIME CERTIFICATION I hereby certify that all information I have provided on this form and other supporting documentation is complete and accurate to the best of my knowledge. Signature Date RELEASE OF INFORMATION The following is OPTIONAL but your assistance in these areas is greatly appreciated: I hereby give permission to Arkansas Single Parent Scholarship Fund to use information about my background, experiences and academic accomplishments in promotional materials. Yes, with my name Yes, but anonymously No If asked, I am willing to speak at civic clubs, churches, or other engagements in which members of the community want to learn about the activities of the Arkansas Single Parent Scholarship Fund. Yes No I hereby give permission for all financial and academic information related to this application including financial aid, number of hours of enrollment, and grades to be released, upon request, to the Arkansas Single Parent Scholarship Fund. I also agree to participate in follow up research conducted by SPSF/VBC after I am no longer receiving scholarship awards and hereby give permission to SPSF/VBC to obtain enrollment and graduation information from my school as is needed for their subsequent reports. Signature Date Updated 04/05/2018 Page 5 of 6
SCHOLARSHIP APPLICATION CHECK-LIST IMPORTANT - THIS APPLICATION WILL BE REJECTED IF: (1) THE APPLICATION IS NOT COMPLETED IN ITS ENTIRETY, AND (2) THE INFORMATION IN THE CHECKLIST BELOW IS NOT INCLUDED WITH YOUR SUBMITTED APPLICATION. Include each of the following: Completed application form (pg 2-5) Signed Release of Information (pg 5) Proof of enrollment - Class schedule for upcoming term or registrar verification. If a class schedule is not available at the time of your application, you may submit verification from the registrar with your application. However, a class schedule must still be provided before your scholarship is awarded. Proof of income - Tax return (first page of most recent year). If you are exempt from filing a tax return, submit a Proof of Income statement from the Department of Human Services. Other income verification may be considered if these documents do not apply to your situation. Pell Grant (FAFSA) copy of your Student Aid Report (SAR), or letter from your school s Financial Aid Office that states your approval or denial for financial aid during the term for which this scholarship is to be used. If you did not apply for FAFSA, provide an explanation. Current transcript - An unofficial copy of your transcript showing your most recent grades, with cumulative GPA. You may download or print this from your school's website. Return these items to: Single Parent Scholarship Fund of Van Buren County c/o Skip Davis PO Box 1394 Fairfield Bay, Arkansas 72088 Phone: (501) 253-5343 Email: oldc9guy@aol.com Updated 04/05/2018 Page 6 of 6