The Scholarship Selection Committee Will Consider the Following Criteria

2013 LILLY ENDOWMENT

COMMUNITY SCHOLARSHIP

Administered by: Heritage Fund – the Community Foundation of BartholomewCounty

The Scholarship Selection Committee will consider the following criteria:

- Academic Performance- Community Involvement

- School Involvement- Student Answered Questions/Short Essay

- Financial Situation (EFC)- Other (i.e., work, first-generation college, special circumstances)

Eligibility Requirements:

A resident of Bartholomew County, Indiana, and have graduated with a diploma from a public or private Indiana high school (accredited by the Indiana Department of Education) by the end of June 2013, but not have graduated before the start of the 2012-2013 school year.Students graduating mid-year are eligible.

Have at least 9.0 GPA on a 12.0 point system or a 3.33 GPA on a 4.0 point system at the end of the sixth

semester of high school. (An official high school transcript is required.)

Able to demonstrate school involvement, community service, good character and leadership skills.

Have been accepted to pursue a full-time baccalaureate course of study beginning in the fall of 2013 at an

accredited public or private college or university in the state of Indiana. (The recipient must notify the

Heritage Fund prior to May 1, 2013, which Indiana college he/she will attend.)

Be available for a personal interview with the selection committee, if chosen as a finalist.

About the Lilly Endowment Community Scholarship:

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

Since the Scholarship Program began in 1998, 33 Bartholomew County students have beennamed Lilly Endowment Community Scholars. The Endowment has awarded more than $1,948,552 collectively to these scholars.

These scholarships provide full tuition, required fees and a special allocation of up to $900 per year for required books and equipment for four years of undergraduate study on a full-time basis, leading to a baccalaureate degree at any Indiana public or private college or university accredited by the North Central Association of Colleges and Schools. The scholarship does not cover room and board expenses.

The Lilly Endowment Community Scholarships are administered by Heritage Fund and the IndependentColleges of Indiana. Up to two Lilly Scholarships may be awarded to Bartholomew County students in 2013.

Scholarship recipients will be notified of the award no later than March 30, 2013.

SUBMIT APPLICATION TO:

HERITAGE FUND, P.O. BOX 1547, COLUMBUS, IN 47202-1547

812-376-7772 • E-mail: • Web site:

APPLICATION DEADLINE: DECEMBER 7, 2012, 4:00 P.M.

Application Procedure:

The following check-off list will assist you in completing the application. A completed application includes:

Completed application including financial information

Student answered questions and short essay (space provided in application, extra sheets
will not be accepted)

Two recommendation forms (more than two will not be accepted)

Official high school transcript

NOTE: IT IS THE APPLICANT’S RESPONSIBILITY TO PROVIDE ALL THE REQUIRED DOCUMENTS TO THE HERITAGE FUND OFFICEON OR BEFORE THE DEADLINE. APPLICATIONS SUBMITTED WITHOUT ALL THE REQUIRED FORMS WILL NOT BE CONSIDERED.ADDITIONAL DOCUMENTS AND/OR RESUMES WILL NOT BE ACCEPTED.

Financial Form:

A completed financial form (included with the application) is a requirement for this scholarship.
Please use 2011 Federal tax information to complete this form.

Short Answer Questions and Essay:

The application includes three short answer questions and a one-page essay. Space for the short answer questions and essay are included in the application. The essay may not be longer than one page (single side)typed in not less than 10-point font and double-spaced.Any additional pages will not be accepted.

Recommendation Forms:

Two recommendation forms must be submitted with your application. One form is to be completed by a classroom teacher you have had during your four years of high school. The second recommendation is tobe completed by a counselor, advisor, supervisor or other professional with whom you have had a workingrelationship. Neither recommender can be related to the applicant in any way. Recommenders should use only the form provided. Additional pages will not be accepted.Information provided on the recommendation forms must be type-written in no smaller than a 10 pt.typeface or legibly handwritten in black ink. It is also acceptable to cut and paste a Word document if youdesire; however, the recommendation must fit in the space provided (one page-one sided).

Official Transcript:

An official high school transcript reflecting the applicant’s sixth semester grade point average, class rank and

standardized test scores is to be included with this application (either electronically by Docufide or printed and placed in a sealed envelope by the high school). Please make sure that all the required information isincluded on the transcript.

All information will remain strictly confidential.

APPLICATION DEADLINE: DECEMBER 7, 2012, 4:00 P.M.

Page 1 of 212013 Lilly Endowment Community Scholarship – Bartholomew County

2013LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

This application must be submitted along with all other documents required for the application process. Do not submit information on other forms/papers …answer all questions on this form only. Please type or write legibly. Please fill out the form completely. If an area on the form does not apply to you, please note “not applicable or N/A”.Application must be type-written or filled out with black ink only. Pencil and other color ink will not be accepted.

PART I:

Student’s Full Name:
Nickname: / Date of Birth:
Residing Address: / County:
Mailing Address (If different than above):
Home Phone: / Student’s Email Address:
Student’s Cell Phone: / Parent’s Email Address:
Name of Parents/Guardians / Relationship to Student:
Daytime Phone:
Student Commitment:
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 an Indiana college.
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 2013-2014 school year.
To assist with the processing of my scholarship payments each semester or quarter and to avoid late fees, I
will forward to Heritage Fund immediately upon receipt all invoices received for tuition and any eligible
fees that may be covered by my scholarship.
I will account for and return to Independent Colleges of Indiana any amount of the special allocation for
required books and required equipment remaining at the end of each 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 Heritage Fund apprised annually by June 1st of my enrollment and academic status during college,
by completing and returning any survey forms provided by the community foundation.
Upon graduation, I will keep Heritage Fund 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 hereby affirm that the information provided on this document is accurate and complete to the best of my knowledge. I understand that falsification of any information may result in the termination of any scholarship awarded. I give my consent for it to be shared with the Heritage Fund Scholarship Committee and its Board of Directors, Lilly Endowment Community Scholars Program Selection Committee and Independent Colleges of Indiana (ICI). Heritage Fund has my permission to use my photograph and any general, non-financial information included in this application for publicity purposes. I agree to comply with the statements listed above.
Student Signature: / Date:
Printed Student Name:
Parent/Guardian Signature: / Date:
Printed Name:

APPLICATION DEADLINE: DECEMBER 7, 2012, 4:00 P.M.

2013LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

Part II

High School You Attend: / MALE / FEMALE
High School City/State: / High School Graduation Date:
GPA: / Class Rank: / Out of: / ACT Composite Score:
SAT Scores Math: / Critical Reading: / Total of Math and Critical Reading:
Are you the first generation among your family members to attend college? / YES / NO
Are you a member of the 21st Century Scholarship Program? / YES / NO
How long have you lived in BartholomewCounty?

Name of university or collegeyou plan to attend, in order of preference:

Name of School / 4-year Tuition / Applied? / Status
1st / $ / YES NO / Accepted Unknown
2nd / $ / YES NO / Accepted Unknown
3rd / $ / YES NO / Accepted Unknown
Intended Major(s): / Minor(s):

List your 5 most important scholastic honors or awards from high school.

Name of Honor/Award / Group Issuing Honor/Award / Year Awarded (9, 10, 11, 12)

List your 10 most important school activities and/or organizations,year(s) in which you are now or have been an active participant (in no particular order), and the weekly hours you have committed to that activity by year in school. Identify any in which you’ve held a leadership position.

Activity/Organization / 9 / 10 / 11 / 12 / Name of Leadership Position
Example:: / - Band/Orchestra / 10 hrs / 10 / 10 / 10 / Secretary (11, 12)
- Student Council / 1 / 1.5 / V.P. (11); Pres (12)

2013LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

List any community involvement or volunteerismin which you are now or have been an active participant (in no particular order), and the weekly hours you have committed to that activity by year in school. Identify any in which you’ve held a leadership position.

Community Involvement/Volunteerism / 9 / 10 / 11 / 12 / Name of Leadership Position
Example:: - Turning Point / - / 2 / 2.5 / 3 / Dance Marathon Committee (11, 12)

Please list any scholarships for tuition, required fees or books you expect to receive or have applied for.

Name of Scholarship / Awarding Institution / # of Years / Total Amount / Status: (Unknown, Approved)
$
$
$
$

How do you plan to finance your education? (100 words max.)

Work History:

Position Held / Employer / From: Mo./Yr. / To: Mo./Yr. / Avg. Hrs./Wk. / Approx. Total Amount Earned
$
$
$
$

2013LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

Part III– Financial

PLEASE READ AND FOLLOW ALL DIRECTIONS CAREFULLY

• Submitting a completed financial form is a requirement for this scholarship. All information will remain strictly confidential. If a question does not apply, please indicate with N/A. Do not leave any space blank.
• Use information from your 2011, not your 2012, tax returns. (Financial information is requested from your 2011 tax returns because most people will not have their 2012 taxes finished by the December 7th scholarship deadline.)
• If you feel you have special circumstances that significantly impact your finances that will not be reflected in this form,please contact the Scholarship Manager at Heritage Fund at (812) 376-7772.
• If selected as a finalist, you may be asked to provide supporting documentation.

Parents’/Guardians’ current marital status (check one):

Mother: / Married/Remarried / Divorced / Separated / Single / Widowed / Deceased
Occupation/Title: / Employer: / Length of Employment:
Father: / Married/Remarried / Divorced / Separated / Single / Widowed / Deceased
Occupation/Title: / Employer: / Length of Employment:
Highest education completed:
Mother: / Unknown / Middle School/Jr. High / High School / Technical/Vocational School
Some College/Associate’s Degree / Bachelor’s Degree of Higher
Father: / Unknown / Middle School/Jr. High / High School / Technical/Vocational School
Some College/Associate’s Degree / Bachelor’s Degree of Higher

If your parents are divorced or separated, please indicate each parent’s monetary contribution to your education.

Father’s Contribution: / $ / Mother’s Contribution: / $
Number in household (include yourself, siblings, parents):
Number of household members who will be enrolled at an accredited post-secondary institution (at least six hours) for the 2013-2014 academic year. Include the Lilly applicant and any siblings/step-siblings. Do not include parents. / Number
Custodial parents’/guardians’ state of legal residence: / Age of older parent:

Please explain any special family, personal or financial situations that the Selection Committee should know about in reviewing your scholarship needs. (150 words max.)

2013 LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

Part III – Financial continued

If you are a Dependentstudent, please have your parents/guardians complete the PARENT section of this form. You must complete the STUDENT section.

To claim independent status, you must (1) have served in the military, (2) be a ward of the courts, (3) be married and living away from your parents, (4) be an emancipated minor, or (5) have not been claimed by your parents/guardians for two consecutive years and have earned at least $4,000 in each of those two years. Circle all of the above conditions that apply (documentation may be required). If none of these conditions apply, the STUDENT and PARENT sections must be completed.

Student / Parent(s)
•Did you file a 2011 income tax return? / YES NO / YES NO
•If you filed a 1040, were you eligible to file a 1040A or 1040EZ? / YES NO / YES NO
•2011 Adjusted Gross Income (1040-Line 37, 1040A-Line 21 or 1040EZ-Line 4) / $ / $
•2011 U.S. Income Tax Paid (1040-Line 71, 1040A-Line 44 or 1040EZ-Line 10) / $ / $
Answer these questions whether or not you filed 2010 tax returns.
•2011 Student’s income earned from work: / $
•2011 Father/guardian income earned from work: / $
•2011 Mother/guardian income earned from work: / $
• Total of: Earned income credit, additional child tax credit, welfare benefits including Temporary Assistance for Needy Families and untaxed Social Security benefits: / $ / $
• Total of: Contributions to tax-deferred pension and savings plans, tax exempt interest income, any other untaxed income or benefits not reported elsewhere (IRA payments, worker’s compensation, etc.): / $ / $
• Total of: Child support paid, education credits, taxable earnings from Federal Work Study, student grants and scholarships included in Adjusted Gross Income: / $ / $
Asset Information (all values as of September 28, 2012)
•Cash, savings and checking accounts: / $ / $
•Net worth of investments value** (net worth = current value minus debt): / $ / $
•Net worth of current businesses/investment farms*** (net worth=current value minus debt): / $ / $

** Investments include real estate, trust funds, money market funds, mutual funds, certificates of deposit, stocks, stock options, bonds, other securities,educational IRAs, college savings plans, installment and land sale contracts (including mortgages held), commodities, etc. Exclude the home you live in,life insurance and retirement plans (i.e., 401k, 403b, Keogh Plan).

*** Businesses and/or investment farm value includes the market value of land, buildings, machinery, equipment, inventory, etc. Debt includes only those debts for which business or farm was used as collateral. Do not include a farm thatyou live on and operate.

2013 LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

Part IV – Short Answer Questions

Question 1: Describe how you have been influenced by an individual or an event and how you believe it will shape your future. (200 words max.)

Question 2: Where do you see yourself in 10 years?(200 words max.)

Question 3: Why should the Selection Committee select you to receive a scholarship? (200 words max.)

2013 LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

Part V – Essay (enter content below, 1-page, double spaced)

There are many local, national, and world issues affecting us today. What issue is a major concern for you and why? Explain what skills and resources you have or hope to develop that would make a difference. (450 words max.)

2013 LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

• Applications submitted without all the required and completed forms will not be considered.
• Completed applications should be turned-in/mailed to Heritage Fund in an envelope marked “2013Lilly Scholarship.”
• Please do not staple any pages of the application (paper clips are acceptable).

Return completed forms to:

Heritage Fund - the Community Foundation of BartholomewCounty

538 Franklin Street, P.O. Box 1547, Columbus, IN47202-1547

APPLICATION DEADLINE: DECEMBER 7, 2012, 4 P.M.

About Heritage Fund:

Heritage Fund - the Community Foundation of Bartholomew County was created in December 1976as the final act of the Columbus/Bartholomew County Bicentennial Corporation. As a communityfoundation, Heritage Fund is a vehicle designed to serve philanthropic donors who want to helpimprove their community.

The concept of a community foundation is to build substantial endowment funds which are permanentlyinvested to produce income. The earned income is then re-invested into the community. Forthe year ending 12/31/11 the foundation disbursed more than $3.9 million in grants and scholarshipsto not-for-profit organizations and students.

Like most community foundations, Heritage Fund does not provide direct services but instead awardsgrants to charities and organizations in our community that best carry out donors’ interests and meetcommunity needs.

Since most of the assets are permanently endowed, Heritage Fund will be able to help meet thecommunity’s charitable needs forever.

About Lilly Endowment:

Lilly Endowment Inc. is an Indianapolis-based, private philanthropic foundation created in 1937 bythree members of the Lilly family - J.K. Lilly, Sr., and sons, J.K., Jr. and Eli - through gifts of stock intheir pharmaceutical business Eli Lilly and Company.

These gifts remain the financial bedrock of the endowment. Lilly Endowment is, however, a separateentity from the company, with a distinct governing board, staff and location.In keeping with the wishes of its three founders, Lilly Endowment exists to support the causes ofreligion, education and community development. Special emphasis is afforded projects that benefityouth and the leadership, education and financial self-sufficiency of the nonprofit, charitable sector.One of the Lilly family’s foremost philanthropic priorities was to help the people of their city and statebuild a better life. Although the Endowment supports efforts of national significance and an occasionalinternational project, it remains primarily committed to its hometown, Indianapolis, and home state,Indiana.

OUR MISSION

Heritage Fund is a community foundation created primarilyfor BartholomewCounty to:

• Provide responsible stewardship of gifts donated for broad charitable purposes;
• Promote leadership to address community issues;
• Serve as a catalyst for positive change in partnership with others; and
• Promote philanthropy broadly within the community.

“It is the general policy of Heritage Fund – the Community Foundation of BartholomewCounty to include people without regard to age, disability, economic circumstances,ethnicity, gender, race, religion or sexual orientation in carrying out our mission.” Adopted by the Heritage Fund Board,May 4, 2003