APPLICATION FOR FINANCIAL ASSISTANCE
Student’s Name: ______
Parent/guardian information:
If parents are divorced, please provide information for custodial parent and stepparent, if any.
In case of joint custody, please fill out two separate forms.
Parent/Guardian #1 Parent/Stepparent/Guardian #2
Name: ______
Relationship to applicant: ______
Occupation: ______
Employed by: ______
Biological parents’ marital status (married, separated, divorced, never married, other): ______
Household Members: (Please list all adults and children, including applicant, supported by household.)
Name Age (for applicant Dependent for Cost of school/college
and siblings only) tax purposes? (after financial aid, for 2015-2016)
______
______
______
______
If applicant or other family members are starting college or private school NEXT year, please indicate this below and list estimated expenses (attach separate sheet if necessary): ______
______
Additional dependents receiving financial support from family:
Name Relationship Tax dependent? Lives with family? Amount of support
______
Household Budget
Family income (before taxes): 2015 2016 (estimated)
Parent/Guardian 1 Salary (including bonuses): ______
Parent/Stepparent/Guardian 2 Salary (including bonuses): ______
Investment Income: ______
Support from other family members: ______
Loans: ______
Other Income (e.g. child support, unemployment, social assistance): ______
Total Income ______
Major expenses:
Taxes (federal, state/provincial, local): ______
Housing (rent/mortgage, utilities, property taxes, insurance): ______
Transportation (car expenses, gas, taxes, insurance, public transit): ______
Medical expenses (including any insurance costs): ______
Life/Disability Insurance: ______
School costs (from page 1): ______
Travel expenses (e.g. family trip): ______
Debt repayment (other than mortgage/car): ______
Unusual expenses (please list: ______) ______
Subtotal ______
Remaining Budget (Income minus major expenses): ______
Family assets and liabilities:
Bank account (checking/savings accounts): ______
Other investments: ______
Real estate:
Present value: ______
Unpaid mortgage: ______
Share in business or farm: ______
Student’s assets (bank account, trust fund, college fund, inheritance): ______
Other indebtedness (excluding mortgage – e.g. car loans, credit card debt): ______
Estimated cost of round-trip travel to Mathcamp for the student: ______
(Please look up the cost online, e.g. at http://www.kayak.com/.)
Portion of the total camp cost ($4000+ travel) that the family can afford to pay:
From household income/assets: ______
From other sources: ______
Total: ______
Special circumstances that we should know about (attach additional sheet if necessary):
______
______
______
______
______
I have checked this form for omissions or errors. To the best of my knowledge, all the information is correct.
Parent’s name ______Date ______
Parent’s email address (or phone, if no email):