2017LRSF SCHOLARSHIP APPLICATION –WRITE INFORM
Deadline: April 1, 2017
(For the 2017-2018 Academic Year - See LRSF Application Instructions for details.)
1. Applicant Information
Last Name:______First Name and Middle Initial: ______
Home Address: (street, city, zip and county): ______
Mailing Address: (if different from Home Address):______
Date of Birth: ______Home Phone:______Cell Phone: ______
Email: ______Gender: ☐Female ☐Male
High School Attended: ______HS Graduation Year:______
Applicant Marital Status (choose one): ☐Single ☐Married ☐Divorced ☐Separated
2. College Information
Name and Location of First College Choice: ______
Intended Major: ______Anticipated College Graduation Year/Month ______
Type of College you plan to attend: ☐4-Year College ☐2-Year College or Technical School
College Status for 4 year college: ☐Freshman ☐Sophomore ☐Junior ☐Senior
☐Grad Student ☐Other
College Status for 2-Year College or Vocational School: ☐1st Year ☐2nd Year ☐Other
Attendance Status: ☐Full Time ☐¾ Time ☐½ Time ☐Less than ½ Time ☐Other
If you chose “other” for any items in this section please explain here:______
______
3. 2017-2018 Academic Year Educational Expenses
Tuition and Fees as listed in college catalogue: / $Room and Board / $
Transportation cost if commuting daily / $
TOTAL (add all amounts) / $
4. Transcript of Grades
Current high school seniors and all students who have completed less than one full semester in college must include an official high school transcript showing the most Current Cumulative Grade Point Average.
All other college students must provide a college transcript that includes the most Current Cumulative Grade Point Average. A computer printout is acceptable if it clearly identifies the student.
5. Parent(s) or Spouse Information
Note: If you are married, complete only the section for your spouse.
Current Marital Status of parents: ☐Single ☐Married ☐Divorced ☐Separated
Father’s (or custodial step-father’s) name: ______
Father’s pace of Employment______Occupation:______Age:______
Mother’s (or custodial step-mother’s) name: ______
Mother’s place of Employment: ______Occupation:______Age:______
Spouse’s name (if applicable):______
Spouse’s place of Employment: ______Occupation:______Age: _____
6.Applicant Dependency Status
You must determine if you are a dependent or independent student by reviewing the Determining Dependency Status section on the last page of the Application Instructions. If you answered “yes” to any of the criteria in numbers 1 through 9, you are considered an independent student and you only need to include financial information for yourself (and spouse and/or children if applicable).
Dependency Status: ☐Dependent ☐Independent
7Loan Information
If you selected “dependent” above, provide information below for all family members including yourself (Applicant), your parents and any siblings under the age of24 who receive more than half their support from you or your parents. Your parents may include any outstanding PLUS (Parent Loan for Undergraduate Students) loans. Additional names may be included on a separate sheet if necessary.
If you selected “independent” above, provide information below for yourself (Applicant) and your spouse and children if applicable.
First Name / Relationship / Age / College / Outstanding LoansApplicant / $
$
$
$
$
$
Total / $
The number of persons listed in Section 7 who will be attending college during the upcoming school year: ______
8. Applicant Work and Community Activities
High School Seniors: List ALL school, community or serviceactivities in which you have participated during the last four years. Please include the approximate number of hours and the year(s) for each activity. (Sports, scholastic, volunteer and community projects, etc.). OR: If available, include your high school resume on a separate sheet with your name at the top.
______
______
______
College Students: List ALL school, community or serviceactivities in which you have participated throughout your college years. Please include the approximate number of hours and the year(s) for each activity. (Sports, scholastic, volunteer and community projects, etc.). This information may be submitted on a separate sheet with your name at the top. We realize that your extra-curricular activities may have decreased due to college workload and employment.
______
______
______
Employment: List place(s) of employment and average number of hours worked during the school year and summer for the past four years. We realize that employment may have curtailed school and civic involvement.
School Year: ______
Summer: ______
9. Clubs & Organizations
Organizations: List any community clubs, organizations, etc. to which you or your family belong or participate. This information is used only for “matching” applicants to awards. ______
______
______
10.*** Required Short Essay ***
IMPORTANT: On a separate sheet of paper – typewritten if possible – submit a short essay describing your specific educational goals and career plans and why your chosen field is meaningful to you. If you are presently unsure of your college major, explain what you hope to gain through your college experience. Please make sure your name appears on the top of the page(s). This section is a vital part of the rating of your application. Keep in mind that this information will be available to donors who wish to know more about you and your scholastic plans and career goals.
11. Unusual Circumstances
Describe any unusual or difficult family or personal circumstances, if any that impact your financial situation. ______
______
12.Financial Information (See Instructions for More Details)
There are two options for providing Financial Information. You may include your 2017-2018 FAFSA Student Aid Report OR you may include the 2015 Tax Return(s) for yourself and your parents or spouse.
Choose either Option A OROption B.
Option A: 2017-2018 FAFSA Student Aid Report:Include all pages of your 2017-2018FAFSA Student Aid Report as a separate attachment. The first page of the report should include your EFC (Expected Family Contribution). You do not have to complete the net worth section below.
If you choose Option A, enter the EFC from your Student Aid Report here: ______
Option B: 2015 Tax Returns or W2 forms: Include all 2015 Tax Returns for yourself and parents (or spouse) as separate attachment(s) or all W-2 forms if a tax return was not filed.
If you choose Option B you must complete the Assets, Expenses and Net Worth section below.
If you choose Option B, enter the total Adjusted Gross Income (AGI) from all tax returnsor the total of all wages from W2 forms here: $______
13 Assets, Expenses & Net Worth Data
(Fill in this section if you chose Option B. Independent students do not need to fil in the section for Parents.)
Applicant (and Spouse) / ParentsCash, Savings, Checking, CD’s / $ / $
Real Estate (other than primary residence) – value minus debt / $ / $
Business (if applicable) – value minus debt / $ / $
Other Investments such as Stocks, Bonds / $ / $
TOTALS / $ / $
Special Note:By submitting this application, you agree that the information on this form is accurate and complete to the best of your knowledge. Falsification of any information will result in the loss of scholarship award(s).
LRSF uses the personal information on this form for evaluation of the applicant for scholarships and for the distribution of award(s) received. Financial information from tax returns or Student Aid Reports is used only for applicant assessment by the Board of Trustees and is not subject to public disclosure.
Checklist:Please use the checklist in the Application Instructions to make sure that you have included all necessary documents.
Please indicate here if your transcript, appraisal form, essayor any other documents will be sent separately by you or another person. ______
______