For Additional Help in Filling out This Form, Refer to the Document Instructions for Scholarship

This form is to be used to give individuals an opportunity to record answers to the questions on the Individual Case History to aid in the filling out of the Individual Case History online. You may NOT turn in this form in place of the online Individual Case History.

For additional help in filling out this form, refer to the document Instructions for Scholarship Committees, located on the online Individual Case History Instructions page.

Name of Scholarship(s):

______Amount Awarded: ______

______Amount Awarded: ______

Sponsoring Chapter: ______State/Province/District: ______

1. Name of Recipient: ______

First MiddleLast

Last 4 digits SS #: ______-OR- Student ID #: ______

Address: ______

______

City State/ProvinceZip/Postal Code

1. Name of School to be Enrolled (must be in U.S. or Canada): ______

Campus Location of School to be Enrolled (City, State): ______

1. Total Scholarship Awarded: $______For School Year (Date/Term): ______

1. For what purpose is the scholarship desired (e.g., tuition, books, fees): ______

______

1. Will the recipient be a high school graduate or have equivalent educational training by the time the scholarship is disbursed? ___ Yes ____ No

1. What criteria were used in selecting recipient (e.g., scholastic standing, financial need, personal recommendations, plans for use of education, acceptance by school of choice?

1. List any restrictions specified by the fund (e.g., field of study, residency requirement, institution to be attended, etc.) and indicate that the recipient meets these requirements.

1. From how many applicants was the recipient selected? ______

1. Is recipient related to donor of fund? ___ Yes ____ No

If yes, what are the name(s) and relation(s) of these individuals?

1. Was selection of recipient at the suggestion or request of donor, a member of the donor’s family or a substantial contributor to the fund? ____ Yes ____ No

If yes, what are the name(s) and relation(s) of these individuals?

1. Is there a family relationship between recipient and a member of the scholarship selection committee? ___ Yes ____ No

If yes, what are the name(s) and relation(s) of these individuals?

1. Is recipient a member of the P.E.O. Sisterhood? _____ Yes _____ No

1. Is there a family relationship between recipient and:

1. A member of the P.E.O. Sisterhood? ____ Yes ____ No

If yes, what are the name(s) and relation(s) of these individuals?

1. A trustee of the P.E.O. Foundation or an officer of the International Chapter of the P.E.O. Sisterhood? ___ Yes ____ No

If yes, what are the name(s) and relation(s) of these individuals?

1. The donor of or substantial contributor to the individual fund or any member of the donor’s or contributor’s family? ____ Yes ____ No

If yes, what are the name(s) and relation(s) of these individuals?

* * * * * * * * * * * * *

Request for Approval of Fund

As authorized by the selection committee, approval of scholarship for the individual listed in #1 is hereby requested.

 I certify that this recipient has satisfied all of the requirements for this scholarship.

Typing your name below constitutes your signature:

Selection Committee chairman’s name: Date:

Chairman Information

Name of Group (committee, executive board) making selection of recipient:

*Name of Chairman:

*Address:

*City:

*State/Province/District:

*Zip Code/Postal Code:

*Country:

*Phone:

*Email:

* * * * * * * * * * *

The detailed information on this form is obtained for compliance with IRS regulations.

Approval by a majority of trustees is required.