EL SOBRANTE CHRISTIAN SCHOOL
STUDENT SCHOLARSHIP APPLICATION
APPLICATION FORM DEADLINE MAY 1, 2017
1. Parent or Guardian 2. Parent or Guardian
Parent or guardian living with student applying for aid (circle one) Parent or guardian living with student applying for aid (circle one)
Father Mother Stepfather Stepmother Father Mother Stepfather Stepmother
Other (specify relationship):______Other (specify relationship):______
______
Last Name First Name MI Last Name First Name MI
______
(Area Code) Home Phone (Area Code) Home Phone
______
Address Apt. # Address Apt. #
______
City State Zip City State Zip
______
Email address Email address
______
Occupation (Area Code)Work Phone Occupation (Area Code)Work Phone
______
Employer How Long? Employer How Long?
May we contact you at work? __Yes __No May we contact you at work? __Yes __No
3. Family Information
Number of family members living in the household during 2016-17 school year:
Parents/Guardians:______Children:______Other (specify relationship):______
If student’s parents are not currently married and living together, please complete the following:
1. Does custodial parent receive child support? ___ Yes ___ No If YES, how much per year $______.00
2. According to court order, when will child support end? ______
3. Is there an agreement specifying a contribution for student’s education? ___ Yes ___ No If YES, how much per year? $______.00
4. Who claimed the children as tax dependents in 2016?______
4. Student Information
______Last Name First Name DOB Grade in Fall
______
School attended 2016-17 Principal (if not ESCS) Telephone Number
HOUSEHOLD INCOME
Instructions:
If you HAVE filed your 2016 IRS form 1040:
You must submit copies of all pages of your IRS form 1080, 1040A, or 1040EZ including all schedules, you must also submit all copies of all 2016 W2 forms from all employers.
If you HAVE NOT filed your 2016 IRS form 1040:
You must submit all copies of all 2016 W2 (and/or 1099) forms from all employers. You must also submit copies of all pages of your 2016 IRS form 1040, 1040A or 1040EZ including all schedules. If this application is being submitted after April 15, 2016, you must also submit copies of your request for an extension.
If you DO NOT file a tax return or you receive non-taxable income:
You must provide a social services grant letter, food stamps verification and/or a Social Security benefits statement for the amounts listed in Section 6.
5. Parents’ or Guardians’ Taxable Income
The information provided is from a tax return that is (check one):
___ Completed ___ Not yet filed ___I/We do not file a tax return (Go to Section 6)
Estimated 2017 Actual 2016
1. Total number of exemptions claimed on Federal Income Tax form ______
2. Father/Stepfather/Male guardian total taxable income from all wages. $______.00 $______.00
Attach all 2016 W2 forms and/or 1099 forms
3. Mother/Stepmother/Female guardian total taxable income from all
wages. Attach all 2016 W2 forms and/or 1099 forms. $______.00 $______.00
4. Net business income from self-employment.
Attach schedules C, E and F. $______.00 $______.00
5. Other non-wage taxable income from interest, dividends,
alimony, unemployment, and non-business income. $______.00 $______.00
6. Total “Adjusted Gross Income”
Attach all pages of your IRS form 1040 $______.00 $______.00
6. Non-Taxable Income received in 2016
7. Spousal support $______.00
8. Child Support $______.00
9. SS/SSI $______.00
10. Retirement Benefits $______.00
APPLICATION IS NOT COMPLETE WITHOUT REQUIRED ATTACHMENTS & SIGNATURES
I understand that the ESCS scholarship will continue only as long as my child is enrolled at ESCS and the tuition and fee payments are kept current. I understand that the scholarship award is not transferable. I further understand that ESCS is solely responsible for scholarship selection and that its decisions are final. If accepted, I hereby permit ESCS to obtain the results of any standardized tests administered by any school (new students). I agree to release ESCS from any liability in connection with this scholarship program. I agree to the eligibility and participation requirements as stated in the 2017/18 ESCS Scholarship Materials. (Form ESCSSIL-1/16)
I declare that the information on this form to the best of my knowledge is true, correct and complete, and I agree to abide by all terms of this application.
______
PARENT OR GUARDIAN SIGNATURE DATE PARENT OR GUARDIAN SIGNATURE DATE
(ESCSSA-1/17)