Porter County Community Foundation, Inc

Lilly

Endowment

Community

Scholarship

Application

PORTER COUNTY COMMUNITY FOUNDATION, INC.

Lilly Endowment Community Scholarship Program

The Lilly Endowment Community Scholarship Program is designed to raise the level of educational attainment in Indiana and leverage further the ability of Indiana’s community foundations to enhance the quality of life of the state’s residents.

To help further this goal, Lilly Endowment is providing funding to enable community foundations in Indiana to offer the scholarship program. In Porter County, three (3) full tuition scholarships will be awarded to residents of Porter County who have graduated from an accredited Indiana high school. Students must pursue a baccalaureate degree at any public or private Indiana college or university accredited by the North Central Association of Colleges and Schools. The scholarship covers a four-year degree program beginning in the fall of 2017including full tuition, required fees, and a special allocation of up to $900 per year for required books and equipment. The scholarship will not extend beyond the four-year period. Medical exceptions will be handled on a case by case basis. Scholarship recipients may transfer from one Indiana college or university to another during the four-year period.

THE SCHOLARSHIP DOES NOT COVER ROOM AND BOARD EXPENSES.

ELIGIBILITY REQUIREMENTS

Applicant must reside in Porter County, Indiana and be a United States citizen.

Applicant must be a graduate of an accredited IndianaHigh School.

Applicant must have applied to at least one Indiana college or university.

Applicant must be accepted at an accredited public or private college or university in Indiana and begin a full-time, four-year baccalaureate course of study beginning in the fall of 2017.

Applicant must be available for an interview by the interview committee on October 24, 2016.

Selection Criteria

Students will be evaluated on financial need, academic accomplishment, ability to communicate, motivation/desire to succeed, activities/leadership and capacity to succeed. The scholarship will be awarded to those that demonstrate that the scholarship will make a difference in their lives.

Application Instructions

Please attach in the following order:

Completed Application Form (typed and signed by applicant)

Essay—In your own words, please provide a one page (no more) essay, typed – 12 point font, describing the following:

Who has been the most influential person in your life and why?

Two letters of recommendation—one from a teacher or school representative and the other from an adult other than a family member.

OfficialHigh School Transcript.

Copy of Official Notification of SAT/ACT Score, if available.

Completed Financial Information Sheet.

Application Deadline

The complete application packet must be signed and returned to your Guidance Counselor by

September 23, 2016.

Lilly Endowment Community Scholarship Program

CERTIFICATION FORM

If I receive this scholarship, it is my intent to pursue four years of undergraduate study on a full-time basis leading to a baccalaureate degree at any Indiana college public or private college or university accredited by the Higher Learning Commission of the North Central Association of Colleges and Schools.

I understand that the total amount of my scholarship is calculated on the basis of my chosen college’s tuition and required fees beginning with the 2017-2018 school year.

To assist with the processing of my scholarship payments each semester or quarter, I will forward immediately to the Porter County Community Foundation all invoices received for tuition and any eligible fees that may be covered by my scholarship.

I will account for the amount of the special allocation spent for required books and required equipment with official receipts and other documentation. I will return to Independent Colleges of Indiana any amount of the special allocation remaining at the end of the school year.

I agree to notify Independent Colleges of Indiana of any scholarship awards I may receive for tuition or required fees from a source other than the Lilly Endowment Community Scholarship.

I will keep the Porter County Community Foundation apprised annually by June 1st of my enrollment and academic status during college, by completing and returning any surveys or forms as may be provided by the Community Foundation.

Upon graduation, I will keep the Porter County Community Foundation apprised annually by June 1st of my education and/or employment status for at least TEN years after graduation, by completing and returning an alumni survey or other forms as may be provided by the Community Foundation.

I understand that my behavior and conduct, both in the classroom and elsewhere, is important if selected as a Lilly Endowment Community Scholar. I understand that my character and conduct at any time prior to and after the selection process may impact my eligibility to become or remain a Lilly Endowment Community Scholar.

I hereby affirm that the information provided on this application is accurate and complete to the best of my knowledge. The Porter County Community Foundation, Inc. has my permission to use any general, non-financial information included in this application for publicity purposes. If selected for a scholarship, I will provide the Porter County Community Foundation with a current photo.

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Applicant’sSignatureDate

APPLICANT INFORMATION Please read the directions with this application before completing.

Name: ______

Last First Middle

Permanent Address: ______

Street Name and Number

______

City Zip Code Email Address

Phone Number: ______Cell Phone (if available): ______

Date of Birth: ______Male  Female 

Month/Day/Year

Father’s Name: ______College Attended: ______

Address: ______

(If different from your address)

Employer: ______Occupation: ______

Mother’s Name: ______College Attended: ______

Address: ______

(If different from your address)

Employer: ______Occupation: ______

Please list the names of your siblings (including step siblings) or children and the year they have/ will graduate from high school. If they have/are attending college, list the name of the institution.

Name High School Graduation Year College Attended

______

______

______

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High School Attended: ______

Graduation Date: ______

G.P.A.:______Class Rank/Size:______SAT Score:______ACT Score:______

How long have you lived in PorterCounty?______

Month/Year

Has anyone in your immediate family attended college? Yes No

If awarded this scholarship, how would you expect to finance your room and board expenses?

Please specify % from the following sources:

Parents______Loans______Your Savings______Other (please explain)______

COLLEGE INFORMATION

I have been accepted by or made application to the following Indiana colleges or universities:

______

______

______

______

______

Major Field of Study: ______

Financial Information

Part I – Family size and number in college

How many people will be in your family during the 2017-2018 academic year?

Include yourself, your parents and their other dependent children.______

Of the number in your family above, how many will be enrolled in college

at least half time during 2017-2018? (Be sure to include yourself, but not your parents.)______

Part II - Student financial information

Please complete the following section using your Federal tax information.

All financial information will be held in the strictest confidence. / 2015
Income Tax Form Filed / 1040EZ or 1040A
1040 (long form)
I did not file
Adjusted Gross Income
IRS Form 1040 – line 37; 1040A – line 21; 1040EZ – line 4
Income Tax
IRS Form 1040 – line 55; 1040A – line 35; 1040EZ – line 11
Amount Earned From Work
Include W-2 wages and business/farm earnings
Other Income: Any other income (see instructions in parent section below).
Assets: Current value of your savings and checking accounts, and any other investments including trust funds

Part III - Parents' Marital Status: (check one box)

My parents are married. (Answer questions below with both parents' tax information.)

My parents are not married, but live together. (Answer questions below with both parents' tax information.)



My parents are divorced and my custodial parent is not remarried. (Answer questions about custodial parent only.)

My custodial parent is remarried. (Answer questions with tax information for your custodial parent and your step-parent.)

My parent has never been married (single) (Answer questions with that parent's information.)

My parent is widowed. (Answer questions with that parent's information.)

Part IV - Parent Financial Information

Please complete the following section using your Federal tax information.

All financial information will be held in the strictest confidence. / 2015
Income Tax Form Filed / 1040EZ or 1040A
1040 (long form)
I did not file
Adjusted Gross Income
IRS Form 1040 – line 37; 1040A – line 21; 1040EZ – line 4
Income Tax
IRS Form 1040 – line 55; 1040A – line 35; 1040EZ – line 10
Amount Earned From Work
Include W-2 wages and business/farm earnings (lines 7, 12, or 18 from the Federal 1040 Form.) / Father______
Mother______
Other Income
Child support received; clergy or military housing allowance or parsonage value; contributions made directly or withheld from your paycheck for IRA/Keogh/401K/403B/SEP/SIMPLE other qualified retirement plans (W2 boxes 12a – 12d, codes D, E, F, G, H, and S), untaxed unemployment and any other untaxed income.
Income Credits: Child support that you paid;
Education credits: (Hope and Lifetime Learning tax credits 1040 - line 49;1040A - line 31)
Current value of your savings and checking accounts
Current net worth of your investments (Net worth is value minus debt. Investment debt is only that debt related to that investment.) Include real estate (do not include the home you live in), trust funds, UGMA, UTMA, money market funds, mutual funds, CD's, stocks, bonds, other securities, Coverdale savings accounts and 529 plans. (report 529 plans as parent asset regardless if the student or the parent are the “owner” of the account.)
Current net worth of your business or farm (Net worth is value minus debt; debt includes only those debts for which the business or farm was used as collateral.) Value includes the market value of land, buildings, machinery, equipment and inventory. Do not include the value of a small business that you own and control and that has 100 or fewer employees. Do not include the value of a family farm that you live on and operate.
For Single Parents: college support from non-custodial parent
Other Expenses (Include childcare or eldercare expenses, unusually high un-reimbursed medical expenses, etc. Explain details on the back of this sheet).

EXTRA-CURRICULAR ACTIVITIES

Please describe those non-classroom activities in which you have participated the past four years. List involvement such as school organizations, service clubs, sports, music, drama, community organizations, church groups, etc.

Organization or Activity:Participation Dates:Recognition, Awards, Offices Held:

______

______

______

______

______

______

______

______

______

______

______

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EMPLOYMENT

EmployerPositionDates

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______

______

______

______

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Lilly Endowment Community Scholarship Program

APPLICANT RECOMMENDATION FORM

The Recommendation Form should be typed if possible. Please complete all applicable information.

Name of Applicant: ______

Address of Applicant: ______

Applicant’s High School: ______

In the space provided, please describe the applicant’s character, school and community leadership abilities, and ambition to succeed.

Signature: ______

Printed Name/Title: ______

Relationship to Applicant: ______

Business/School/Home Address: ______

Phone Number: ______Date: ______

Lilly Endowment Community Scholarship Program

APPLICANT RECOMMENDATION FORM

The Recommendation Form should be typed if possible. Please complete all applicable information.

Name of Applicant: ______

Address of Applicant: ______

Applicant’s High School: ______

In the space provided, please describe the applicant’s character, school and community leadership abilities and ambition to succeed.

Signature: ______

Printed Name/Title: ______

Relationship to Applicant: ______

Business/School/Home Address: ______

Phone Number: ______Date: ______