Date Application received________________
Tuition Assistance Request Form
2009-10 School Year
In order to be considered for tuition assistance from
income tax return for 2008. Please submit this form no later than May 18, 2009.
Family Last name:______________________________________________________________
Father’s First name:_____________________________________________________________
Mother’s Name:________________________________________________________________
Address of Family______________________________________________________________
______________________________________________________________
______________________________________________________________
Alternate address if parents do not live together
______________________________________________________________
______________________________________________________________
______________________________________________________________
Father’s Employment: Mother’s Employment:
Position held: Position held:
How long with employer? How long with employer?
Self Employed_______________________ Self Employed_______________________
Dependents
List all dependent children, including college students
Name Age Name
of school and grade Tuition charge Aid
1.
2.
3.
4.
5.
Household
Information
v Number of individuals in household during 2009-10 SY
Adults:______________ Children under 18 yrs:______________
Other:_______________ (explain relationship)
v Current marital status
_____Single/never married
_____Married
_____Widowed
_____divorced
_____remarried
_____separated
_____residing with significant other
_____other__________________
If divorced,
separated, or single
v
Non-custodial parent’s
name:__________________________________________
v
Do you receive or pay child support?
___Receive $_____________per year
___Pay $_____________per year
___Neither
v
Who claimed student as tax dependent in 2008?_________________________________
v
Who is responsible for tuition of dependents
listed earlier?_________________________
Housing
v Do you rent or own your residence _____rent _____own
If renting, what is monthly rent? $_______________________
If own,
o What is your monthly mortgage payment $_____________________
o Any home equity loan amounts, (month) $_____________________
o Current market value of home $______________________________
Non Taxable Income
List the total amount received from 1/1/08 – 12/31/08 for all recipients in household.
v child support $____________ year
v cash assistance $____________ year
v food stamps $____________ year
v social security (SSI/SSD, etc.) $____________ year
v housing assistance $____________ year
v worker’s comp, disability, etc $____________ year
v pension, retirement $____________ year
v loans or gifts $____________ year
v personal savings account $____________ year
v student scholarships or
tuition assistance $____________ year
v other $____________ year
Assets/Investments (as of 12/31/08)
Do you own a business?
Yes_____ No______
Do you own a farm?
Yes_____ No______
Amount in savings $_________________________________
Do you own real estate other than primary residence?
Yes_____ No______
Total value of IRA, 401K, Keogh or other retirement accounts $____________________
Total value of money market funds, stocks, loans, etc. $__________________________
Unusual circumstances
_____loss of job
_____recent divorce or separation
_____change in family living status
_____change in work status
_____bankruptcy
_____college expenses
_____income reduction
_____illness or injury
_____death in the family
_____shared custody
_____high debt
_____child support reduction
_____medical/dental expenses
_____other
Please further explain if
appropriate why you need tuition assistance from
Amount of tuition assistance requested: $________________________________________
We declare the information on this form to be correct and complete to the best of our knowledge
Parent A:____________________________________ Date_________________________
Parent B:____________________________________ Date_________________________
Please don’t forget to include your most
recent income tax return.
Decision by
Date: