Financial Need Statement

Financial Need Statement

Submit this form only one time per academic year, even if you are applying for multiple scholarships.

  • Name *
  • Address *
  • Phone * - -
  • Date of Birth * / /
    Pick a date.
  • Section I: Student Information - All Students must answer

  • 1. Were you born before January 1, 1993? *
    1. Were you born before January 1, 1993?
  • 2. As of today, are you married? *
    2. As of today, are you married?
  • 3. Are you in a graduate program of study? (e.g. master's or doctorate program) *
    3. Are you in a graduate program of study? (e.g. master's or doctorate program)
  • 4. Do you have at least one child that you support? *
    4. Do you have at least one child that you support?
  • 5. Do you have dependents other than your children or spouse that you support? *
    5. Do you have dependents other than your children or spouse that you support?
  • 6. Are you an orphan or ward of the court? *
    6. Are you an orphan or ward of the court?
  • 7. As of today, are you an emancipated minor as determined by a court? *
    7. As of today, are you an emancipated minor as determined by a court?
  • 8. As of today, are you in legal guardianship as determined by a court? *
    8. As of today, are you in legal guardianship as determined by a court?
  • 9. Did your high school or school district homeless liaison determine that you were an unaccompanied youth who was homeless? *
    9. Did your high school or school district homeless liaison determine that you were an unaccompanied youth who was homeless?
  • 10. Did the director of an emergency shelter program funded by the U.S. Department of Housing and Urban Development determine that you were an unaccompanied youth who was homeless? *
    10. Did the director of an emergency shelter program funded by the U.S. Department of Housing and Urban Development determine that you were an unaccompanied youth who was homeless?
  • 11. Did the director of a runaway or homeless youth basic center or transitional living program determine that you were an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless? *
    11. Did the director of a runaway or homeless youth basic center or transitional living program determine that you were an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?
  • For purposes of this application, if you answered “No” to all of the questions above, you are considered a dependent student and must include parental income information on this form.

    If you answered “Yes” to any of the questions above, you are considered an independent student and therefore, not required to include parental income information on this form. An independent student who is married must include information about his or her spouse.

  • Section II: Household Information

  • 12. If you are a dependent student, please list the names of ALL family members who will be supported by your parents from July 1, 2017 to June 30, 2018 If you are an independent student, you should include family members who are supported by you. (See instructions for additional information.) Attach additional sheets if necessary.

  • Name
  • Date of Birth / /
    Pick a date.
  • Name
  • Date of Birth / /
    Pick a date.
  • Name
  • Date of Birth / /
    Pick a date.
  • Name
  • Date of Birth / /
    Pick a date.
  • Section III: Additional Information

    We use prior year’s income tax return to determine need

  • Student:

  • 13. Did you file a U.S. federal income tax return for 2016? *
    13. Did you file a U.S. federal income tax return for 2016?
  • 14. Housing plans for 2017-2018: Where do you plan to live? *
    14. Housing plans for 2017-2018: Where do you plan to live?
  • 15. At the start of the 2017-2018 school year, I will enroll: *
    15. At the start of the 2017-2018 school year, I will enroll:
  • Parent:

  • 16. Did you file a federal income tax return for 2016? *
    16. Did you file a federal income tax return for 2016?
  • 17. Marital status: *
    17. Marital status:
  • Section IV: Income and Assets

    Do not leave any blanks. Enter “0” where appropriate.
    Dependent students: Complete both the Student and Parent columns.
    Independent students: Complete the Student/Spouse column only.

  • Part A. Annual Untaxed Income

  • 20. Child support received

  • Student/Spouse $ .
  • Parents $ .
  • 21. Tax exempt interest income

  • Student/Spouse $ .
  • Parents $ .
  • 22. Housing, food, and other living allowances paid on your behalf

  • Student/Spouse $ .
  • Parents $ .
  • 23. Other untaxed income not reported, such as worker's compensation, disability, etc.

  • Student/Spouse $ .
  • Parents $ .
  • 24. Money received, or paid on your behalf (e.g. bills) not reported elsewhere on this form

  • Student/Spouse $ .
  • Parents $ .
  • 25. Wages not listed on taxes or W-2 forms

  • Student/Spouse $ .
  • Parents $ .
  • Part B. Annual Income Exclusions

  • 26. Child support paid

  • Student/Spouse $ .
  • Parents $ .
  • 27. Taxable earnings from work-study or other need-based work programs

  • Student/Spouse $ .
  • Parents $ .
  • 28. Scholarships and grants reported on 2016 income tax return

  • Student/Spouse $ .
  • Parents $ .
  • Part C. Assets

  • 29. As of today, balance of cash, savings, and checking accounts

  • Student/Spouse $ .
  • Parents $ .
  • 30. As of today, investment net worth (do not include the home you live in or the balance of retirement plans)

  • Student/Spouse $ .
  • Parents $ .
  • 31. As of today, net worth of current business or investment farms

  • Student/Spouse $ .
  • Parents $ .
  • Section V: Total Family Income

  • 32. Was your TOTAL FAMILY INCOME less than $6500 in 2016? (Total family income is the income reported on your parents’ and your W-2 IRS tax forms plus the total untaxed income reported on Section IV, Part A of this form) *
    32. Was your TOTAL FAMILY INCOME less than $6500 in 2016? (Total family income is the income reported on your parents’ and your W-2 IRS tax forms plus the total untaxed income reported on Section IV, Part A of this form)
  • Clear
  • Date * / /
    Pick a date.