Graduate Students’ Association
Individual/Family Bursary Evaluation Criteria
Fall Deadline: Friday, November 11th , 2016
Winter Deadline: Friday, February 10, 2017
*Successful applicants are eligible for up to $1000.00 of funding individual or $2000.00 family
Please note that if the total amount of funding requested by applicants exceeds the amount available to us, we will not be able to fund every eligible applicant.
Questions regarding this application should be directed to:
The GSA Awards Chair:
A. APPLICANT INFORMATION
1. Name: SURNAME: GIVEN NAMES:
2. U of C ID#:
3. Faculty:
Department:
Degree:
Degree Start Date:
Expected Completion Date:
4. On-Campus Mailing Address: Department: Building: Room:
5. Home Phone:
Work Phone:
E-mail:
6. Which bursary are you applying for? Individual Bursary Family Bursary
7. Are you eligible to work? Yes No
Do you work? Yes No
8. Marital Status: Single Married Common-law Separated Divorced Widowed
If married or common-law, is your spouse residing with you? Yes No
Date of marriage or common-law:
Name of spouse:
Is your spouse eligible to work? Yes No
Does your spouse work? Yes No
If separated or divorce, date of separation or divorce:
8. Number of dependent children: Ages:
Are they residing with you? Yes No
9. Are you an international student? Yes No
If yes, do you get your differential fee reimbursed? Yes No
(Note: If you are an international student, you must complete Appendix I for your application to be considered complete)
B. BURSARY INFORMATION
1. Have you received a GSA bursary (individual of family) before? Yes No
2. Has your spouse or common-law partner received a GSA bursary before? Yes No
If you answered ‘yes’ to either of the previous two questions, please complete the table below:
Bursary Type(family or individual) / Applicant
(self or spouse) / Program
(Masters’ or PhD) / Year of Award
3. Indicate which of the following awards you are eligible for and whether you have received funding from these sources.
Granting Body / Have you applied? / Have you received? (if applied) / Value (if received)NSERC/SSHRC/CIHR / Yes No Ineligible / Yes No Don’t know yet / $
Alberta Ingenuity/iCORE/AHFMR / Yes No Ineligible / Yes No Don’t know yet / $
FGS Internal Scholarships / Yes No Ineligible / Yes No Don’t know yet / $
Canada Student Loans / Yes No Ineligible / Yes No Don’t know yet / $
Provincial Student Loans / Yes No Ineligible / Yes No Don’t know yet / $
Bank Loans / Yes No Ineligible / Yes No Don’t know yet / $
4. List any other scholarships or bursaries applied for, apart from those listed in 3 above, noting any that you have received. Attach additional pages if necessary.
Granting Body / Have you received? / Value (if received)Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
Yes No Don’t know yet / $
5. Complete this budget for a 12-month period beginning September 1, of the current academic year. Remember to include any resources/expenses from spouse if married/common-law. Earnings should be given after income tax deductions. Attach additional pages as necessary.
INCOME / (Monthly) / EXPENSES / (Monthly)Loans / $ / Annual
Assistantships / $ / Tuition / $ / /12→ / $
Fellowships / $ / Books / $ / /12→ / $
Scholarships / $ / Additional Fees / $ / /12→ / $
Spousal Earnings / $
Family support / $ / Monthly
Savings / $ / Living Expenses (See Appendix 2) / $
Additional Resources (specify): / $
Part Time Work / $ / Extenuating Circumstances (ie. disability, theft) / $
Differential Fee Reimbursement / $ / $
$ / Additional Living Expenses (if necessary – see Appendix 2) / $
$
$ / $
$
$
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
TOTAL INCOME / $ / TOTAL EXPENSES / $
/ TOTAL INCOME minus
TOTAL EXPENSES: / $ per month
C. PERSONAL STATEMENT
INSTRUCTIONS:
Please answer the following questions (12 point font, single-spacing permitted) providing the committee with a description of your personal situation, in the space provided. In particular, please be sure to discuss:
The Personal Statement is crucial as a standard form like this can only provide a rough picture of a person's situation. Completion of each question is MANDATORY for the application to be considered complete. (Note: A large emphasis will be placed on steps that you are taking to improve your situation)
1. Please describe the degree of your financial difficulties.
2. To what extent were your financial difficulties unforeseeable or unavoidable?
3. What steps have you taken so far to improve your financial situation?
4. If you or your spouse are not currently employed, why not?
5. How will the bursary help you resolve your financial difficulties?
D. SIGNATURES
By signing this application, I confirm that:
1. I have answered all questions on this form that are applicable
2. All information provided is true and complete
3. I will notify the GSA office and return the funds awarded if the submitted project/conference/workshop/course is cancelled or delayed by more than four months
4. I authorise the GSA to use the information provided on this application for research and statistical analysis only; subject to FOIP
5. I have read the Terms of Reference and Evaluation Criteria for this award
Applicant’s name (printed) / Applicant’s signature / Date