Please fill in all requested information. Assistance in completing the application is available at the Recreation Division Office. Any forms that are not completely filled out will NOT be accepted. NOTE:Income information MUST be supplied on ALL persons living in the household who are 18 years old or older whether related to you or not!!! Awards amounts will be available 1 week afterwe receive the application. Registration between February 14thandMarch 3rd will require a utility bill and photo ID with address as proof of residency.

The following household information must be stapled to this application in order to process:

  1. A copy of your 2013 Federal Tax Forms #1040 for all filing residents of household or your 2012Federal Tax Forms #1040 plusthree (3) current consecutive pay stubs for each person 18 years of age or older in the household. All such persons MUST be identified on opposite page.
  2. Documentation of any additional income not reported above – alimony, social security, rental income…

Program scholarships are funded by the Town of Weymouth's Community Services Account. They are intended to benefit low and moderate-income residents. Children ages 3 – 16 are eligible.

Scholarship awards will not have to be matched and they can be used from February 14, 2014through December 31, 2014.

Below are the income guidelines for the 2014 season. These guidelines indicate your household income as reported for 2013.

2013 - Income Guidelines for Total Household (related and non-related)

Total Household Size / 2013 Gross Income / Total Household Size / 2013 Gross Income
1 / NA / 5 / $59,000.00
2 / $44,000.00 / 6 / $63,000.00
3 / $49,000.00 / 7 / $67,500.00
4 / $56,000.00 / 8 / $72,000.00

Personal Data: Please check the box next to name of all adults over 18 years of age and the box of all children you want considered.

Household Address:______Town:______Zip Code:______Home phone #:______

Household members full names Relationship to Applicant (if any) Soc. Sec. # Age Grade School / Employer

Adult Applicant______

______

______

______

______

______

PENALTY FOR FALSE OR FRAUDULENT STATEMENT - U.S.C. Title 18, Section 1001

“Whoever, in any matter within the jurisdiction of any department or agency or the United States knowingly and willfully falsifies or makes any false, factitious, or fraudulent statements or representations, or makes use of any false writing or document knowing the same to contain false, fictitious, or fraudulent statements or entry, shall be fined not more than $10,000; or imprisoned not more than five years; or both.”

Privacy Act Statement

The information that you will be requested to provide as part of your application will be used to determine your eligibility. Although voluntary, failure to furnish any of the requested information may result in rejection of your application. This information may be disclosed to your employer for employment and wage verification; but to no other parties except as permitted by law.

The below named applicant certifies that all information in this application is true to the best of his or her knowledge and belief. Verifications may be obtained from any source named herein.

Applicant signature: ______Date: ______Application deadline: none

Office use only: 2013 1040 form or 2012 1040 + 3 recent pay stubs from all household adults Resident Census of Household

S:\2014\Forms\Scholarship Application 2014.docx