Pat Bland Memorial Scholarship

The mission of the Pat Bland Memorial Scholarship is to provide financial assistance to a Magnolia High School graduating senior planning to attend a four-year West Virginia college to study Education. The recipient must plan to become a teacher, administrator, or guidance counselor upon graduation.

Award:The award is one (1) $1,000 scholarship.

Deadline: March 1, 2017

Return application and attachments to the guidance department.

CHECKLIST

Essay (typed, 500 words) addressing the following prompt - Describe your plans and aspirations for college and beyond. Explain what has led you to choose this path. Please put your name in the
upper right corner of each page.

Activities Form - Use the included form to provide information on extracurricular activities, awards and honors, community and volunteer activities, and work experience.

Current or Most Recent Transcript (in sealed envelope – official copy)

Financial Information Form

  • Provide up to date information utilizing all financial data applicable from the FAFSA,
    financial aid detail from your school, 2015 tax returns and information requested within the financial form. Please do not include tax returns with your application.

STUDENT INFORMATION

Name______

Address______

Street/PO BoxCityStateZip

Telephone______Email______

Father's Name______Occupation______

Mother's Name______Occupation______

US Resident yes  noDate of Birth______

High School Attended______

School Address______

StreetCityStateZip

Telephone______Guidance Counselor______

UNIVERSITY INFORMATION

University Name______

Address______

StreetCityStateZip

Major______

Enrollment Status full-time (12+ hours) part-time (6-11 hours)
Please include a copy of the letter confirming your acceptance to the above listed institution

CERTIFICATION

I, the student, completed this application and certify that the information provided in this application is complete and accurate to the best of my knowledge. I understand that falsification of information will result in termination of any scholarship awarded. I certify that I have read the instructions and will comply with all requests for documentation for financial need and academic status. Should I receive a scholarship, I will notify the CFOV of any change of plans, and the CFOV may use my name and likeness in related publicity materials.

______

SignatureDate

ACTIVITES FORM

Extracurricular Activities / Year / Position Held
Fr / So / Jr / Sr
Community/Volunteer Activities / Year / Position Held
Fr / So / Jr / Sr
Awards and Honors / Year / Comments
Fr / So / Jr / Sr
Work Experience / Dates of Employment / Position Held

Financial Form

If you are a dependent applicant, please have your parents complete this form using information from their 2015 Federal Income Tax Return.
If you are an independent applicant you do not need to supply parental information. You (and spouse, if applicable) will also use information from your 2015 Federal Tax Return.
Documentation:
Please include the page of the FAFSA Student Aid Report that provides your Expected Family Contribution.
DO NOT include copies of tax returns. The information you provide should be taken from the return.
We will notify you if the selection committee requests additional detail pertaining to the reported figures. Providing fraudulent information will result in revocation of any awarded scholarships and/or other related penalties.
Applicant status:

Dependent Applicant (using parental information)  Independent Applicant (using your information)

  1. Adjusted Gross Income (as reported on 2015 tax return) $______
  1. Annual Income Earned$______(Father)$______(Mother)

$______(Student)$______(Spouse)

Parent(s)Student

  1. Untaxed income/benefits (AFDC, ADC, SSI, etc.)$______$______

Source of Benefit ______

  1. Cash, Savings, Stocks, Bonds, CDs, Etc.$______$______

(exclude retirement funds, i.e. IRA)

  1. Net value of real estate holdings not used as a$______$______

primary residence (market value less mortgage balance)

  1. Total number in household: _____ Total number attending college in 2017-2018 school year: _____
  1. Estimated Family Contribution (EFC) from FAFSA Student Aid Report: ______

Father’s Occupation ______Mother’s Occupation ______

Student’s Occupation ______Spouse’s Occupation ______

Parents’ marital status: single  married  separated  divorced  widowed

Applicants’ marital status:  single  married  separated  divorced  widowed

If you wish, you may include a supplementary financial statement explaining circumstances impacting financial need that are not apparent from the above financial information. For example, contributions expected/not expected from a non-custodial parent, educational expenses of siblings, medical expenses, etc.

Expenses

Please refer to the cost of attendance budget at your first choice school. The information should be available in the institution’s publications or from the financial aid office.

Estimated Total Expenses for Coming Year

Tuition and fees:$______

Room and board: $______

Books:$______

Personal/Other Expenses:$______

Total Expenses:$______

Income

List as many items as you can estimate at this time. If you have received a financial aid notice from your first choice school, you should refer to that.

Total Income Available for Coming Year

Income from outside job:$______

Income from campus job:$______

GI or SSI Benefits:$______

Child Support:$______

Alimony:$______

Student’s Savings:$______

Parents’ Contribution:$______

Scholarships:$______
(any you’ve already been awarded)

Loans:$______

Gifts:$______

Grants:$______

Other Income:$______

Total Income:$______

Certification:

I (we) certify that all the information on this form is true and complete to the best of my (our) knowledge. If asked by an authorized official of the Community Foundation for the Ohio Valley, Inc. I (we) agree to give documentation for the
information given on this form. I (we) realize that failure to comply with a request for further information may prevent the applicant from receiving aid.

Applicant’s Signature ______Parent or spouse Signature ______