Confidential Statement for Financial Assistance

Please list all individuals who are and/or will be providing any level of financial assistance to you during the 2012-2013 academic year, including living expenses and educational assistance. The term living expenses is used here to include any subsistence costs paid for your support by someone else, including housing, rent, utilities, food, clothing, transportation, healthcare, etc. Examples of individuals include parent(s), step-parent(s), legal guardian(s), other family member(s), or any non-family member(s). Other types of financial assistance for your benefit must also be reported, including supplemental security income, child support, trust fund income, etc. Do not list scholarships received or financial packages from your educational institution, as these are to be listed on Student/Applicant page.
Dollar amount contributing to your 2012-2013 education costs

Name and relationship to applicant

Address, street, city, state, phone number of relation

1. 2. 3. 4. 5.

$ $ $ $ $

Other Family Members Education costs for 2012-2013: Please list the other members of your immediate family who are in private school or attending a postsecondary school/college.
Name Age Name of school/college Grade level Annual educational costs paid out of pocket for 2012-2013 Name of relation responsible for payment

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Income from federal tax return for the past three years (required) If filing Form 1040, use adjusted gross income Line 37. If filing Form 1040A, use adjusted gross income Line 21. If filing 1040 EZ, use adjusted gross income Line 4. Adjusted Gross Income Current and/or estimated 2011 2010 2009

Parent/Guardians Financial Information

Assets

Home (if owned) estimated market value College savings, 529 plans, etc. Other asset(s) Ex: car/boat/rental property, etc. Checking account balance(s) Savings account balance(s) Other investments (non-retirement) Stocks/Bonds Mutual funds Other

$ $ $ $ $ $ $ $ $ $

Total Assets: Liabilities

Mortgage balance Car loan(s) Home equity loan(s) Educational loans(s) Other (List) Consumer debt (credit cards) Total Loans: Other extraordinary expenses not listed above

$ $ $ $ $ $ $ $ $ $ $ $

Total Liabilities:

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Student/Applicant Data
Current employer Position/job title

Name of Student/Applicant Dependent name(s)

Are you married? Do you have any dependents? Dependent age(s)

Yes No Yes No

Do you own a car? ( ) Yes ( ) No Date of loan

Make/model Lender

Year

Loan Balance Balance owed

Educational Loans Starting date of Monthly payment repayment

College Information
Name and address of college you plan to attend/are attending Annual tuition Annual Room/Board Other TOTAL Annual Cost Expected year of graduation $ $ $ $ $ $ $ $ $ $ $ $

Anticipated plan to pay for college Parental support Student assets Student income Loans Gifts or other support College savings plan Total funds for college Balance needed

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Income from Federal Tax Return for the past three years (required) If filing Form 1040, use adjusted gross income Line 37. If filing Form 1040A, use adjusted gross income Line 21. If filing 1040 EZ, use adjusted gross income Line 4. Adjusted gross income Checking account(s) Saving account(s) Other assets If you have indicated you have no reported income, please explain how you support yourself? This is required if you report no income. 2011 (May be estimated) 2010 2009

Student/Applicant Financial Data

Other information that you wish the Scholarship Committee to know about your financial need.

Once all 4 pages are completed, this form must be uploaded to Page 3 of the Universal Scholarship Application.

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