A Program of the Education Foundation Osceolacounty

A program of the Education Foundation~ OsceolaCounty

Student Scholarship Application

Take Stock in Children scholarship recipients receive:

A Scholarship

A full-tuition, 2 year Florida Prepaid College Scholarship (2 years tuition at a Florida college)

A Mentor

A mentor who meets weekly with the student on school property in cooperation with the school and parent(s)/guardian(s); mentors assist and encourage students in achieving their full potential

Applications are due no later than4:00 PM on Wednesday, February 26, 2014at the Education Foundation/Take Stock in Children office, located at 2310 New Beginnings Road, Kissimmee, 34744. Incomplete applications will not be accepted.

Please call Cindi Junkins, TSIC Program Managerat (407) 870-4855if you have any questions about this application.

PLEASE REMOVE THIS PAGE BEFORE SUBMITTING APPLICATION.

INCOME ELIGIBILITY GUIDELINES

HOUSEHOLD SIZE / ANNUALLY / MONTHLY / TWICE PER MONTH / EVERY TWO WEEKS / WEEKLY
1 / 20,665 / 1,723 / 862 / 795 / 398
2 / 27,991 / 2,333 / 1,167 / 1,077 / 539
3 / 35,317 / 2,994 / 1,472 / 1,359 / 680
4 / 42,643 / 3,554 / 1,777 / 1,641 / 821
5 / 49,969 / 4,165 / 2,083 / 1,922 / 961
6 / 57,295 / 4,775 / 2,388 / 2,204 / 1,102
7 / 64,621 / 5,386 / 2,693 / 2,486 / 1,243
8 / 71,947 / 5,996 / 2,998 / 2,768 / 1,384
For each additional family member, add / 7,326 / 611 / 306 / 282 / 141

To determine monthly income:

*If you receive the income every week, multiply the total gross income by 4.33.

*If you receive the income every two weeks, multiply the total gross income by 2.15.

*If you receive the income twice a month, multiply the total gross income by 2.

Reminder: Total income before taxes, social security, health benefits, union dues, or other deductions must be reported.

Income Guidelines provided by USDA.

Please submit proof of income (copy of tax return for 2012, and copy of the most recent one month’s pay stubs, and/or evidence of government public assistance such as Food Stamps/Cash). Proof of your income MUST be attached in order for your student to be determined eligible for the scholarship. We cannot make copies for you.

Note: We strongly suggest you drop off your application so that yourapplicationcan be immediately reviewed for completeness. When dropped off, if not complete, we will indicate what is missing and will return it to you for completion. Incomplete applications received by mail will not be returned. Applications MUST be complete in order to be considered. Therefore, we ask that you review the entire application before submitting. Applications received after 4:00pm on Wednesday, February 26, 2014 will not be considered.

Review the following checklist to ensure you have included everything.

All names and addresses are complete.

Both mother AND father are listed, even if divorced or deceased (there is additional space to list step-parent information)

ALL persons living in the household are listed.

All addresses and phone numbers of employers are listed.

Copy of 2012 tax return is attached.

Copy of current one (1) month’s worth of pay stubs are attached (4 if weekly, 2 if bi-monthly) along with any other proof of income.

 If you receive Cash Assistance and/or Food Stamps, current qualifying letter with names and amounts received.

 If you and/or a family member receive Social Security, current qualifying letter with amounts received.

Student information and statement are handwritten by the student.

Parent/guardian statements are complete.

Student has signed the application.

Parent/Guardian has signed the application.

Scholarship Application

Student Identification Information

Student Name:______Social Security #:______

Address:______Home Phone:______

City:______State: __ Zip:______Cell Phone:______

Email:______Gender:  Male  Female

Date of Birth: (month/day/year)______

How long have you lived at current address?______Years lived In OsceolaCounty? ______

Is student a U.S. Citizen? yes  no

School ______Grade______Age ______

Does this student have a Florida Prepaid Account? Yes  No 

Household Information – All information must be filled in, even if divorced or deceased;

mother:______Social Security #:______

(first, last name)Email:______

Date of Birth: (month/day/year)______Age:______Last Grade Completed in School:______

FATHER:______Social Security #:______

(first, last name)Email:______

Date of Birth: (month/day/year)______Age:______Last Grade Completed in School:______

Applicant lives with: Mother____% Stepmother Grandmother Guardian

 Father____% StepfatherGrandfather Ward of Court

 Other______

Number of brothers ______Number of sisters ______

Please list all persons living in the home other than student/applicant:

NameAgeRelationshipLast GradeCompleted

______

Independent siblings living outside the home:

NameAgeBrother/SisterCurrentlyLast Grade

(Check One)AttendingschoolCompleted

______brothersisteryes no______

Parent/Guardian’s Current Employer

Name of Parent/Guardian______

Employer______

Occupation ______Work Phone Number______

Address of Employer______

(Street)(City)(State)(Zip)

Number of years with Current Employer ______Gross Monthly Salary ______

(Before Taxes)

Parent/Guardian’s Current Employer

Name of Parent/Guardian______

Employer______

Occupation______Work Phone Number______

Address of Employer______

(Street)(City)(State)(Zip)

Number of years with Current Employer ______Gross Monthly Salary______

(Before Taxes)

Financial Information

What is your annual grosshousehold income? $ ______

(Before Taxes)

Are you eligible to receive any social service?Yes No 

(Food Stamps, Medicaid, etc.)

Please check the services you currently receive:

Public Assistance (cash benefit) Food Stamps  Medicaid 

* If you receive cash and/or Food Stamps, please submit current qualifying letter with names and amounts received.

Are you currently receiving assistance from your local Workforce Development Office? Yes  No 

Do you receive income from any other source? (Social Security, child support, etc.?) Yes  No 

If Yes, please list type of support and amount per month:______

______

Do you or the student/applicant have a savings account?Yes No 

Approximate balance: $ ______

Do you own your own home?Yes No 

If yes, what is the amount of your monthly payment? $ ______

If yes, how much did your house cost? $ ______

Do you rent?Yes No 

If yes, what is the amount of your monthly payment? $ ______

Please submit proof of income (copy of tax return for 2012) and copy of the most recent one-month’s pay stubs (or other proof of income eligibility). Proof of income MUST be attached to determine eligibility. We cannot make copies.

Student Information -Must be in student’s handwriting

List activities, interests, strengths, hobbies or awards you have received (church, school, community, work experience, etc.)

Student Statement -Must be in student’s handwriting

Please tell about your goals, aspirations and hopes for your future.

Parent/Guardian Statement - To be completed by parent(s)/guardian(s)

Apart from financial considerations, how could this program benefit your child? Please include your goals, aspirations and hopes for your child’s future.

Please list any special family situations that might be relevant to school success (see examples).

I certify that the information contained in this application is accurate and understand it will be shared with the Take Stock in Children selection committee and the implementers of the program. I also certify that my child meets the program income requirements. I understand that any false information in this application may result in my child losing his or her eligibility for the program.

______

Student Signature Parent/Guardian Signature

* TSIC will attach a copy of your child’s permanent record to this form.

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