Boone County Single Parent Scholarship Fund Application

 

Deadline:  Fall (August 15)        Spring (December 15) Summer (May 15)

 

PERSONAL INFORMATION:

 

Application Date:__________________________

 

Semester Applying For:   Fall 20_____   Spring 20_____           Summer 20_____

 

1.      Name: ______________________________________________________________M______F______

Last                                         First                         Middle                                      Maiden                                     Sex

 

2.      Address: ____________________________________________            Home Phone:________________

 

         ____________________________________________           Work Phone:________________

            City                                                         State        Zip Code

 

3.      Social Security #: ___________________________         Birthdate: _______________________________

 

4.        Circle One:             Single                     Married                  Divorced                Legally Separated                    Widowed

 

5.      Emergency Contact:  ___________________________________________________________________

                                                      (Name)                               (Relationship)                                                       (Phone)

     

6.      How long have you been a Boone County Resident: ______________Years  ________________Months

 

7.      Including yourself, how many individuals are dependent on you for financial support? ______________

 

8.      List the following information:

Children’s Name	Age	Date of Birth	Type of  Medical Insurance

 

9.      Is anyone else sharing your household expenses? (excluding government assistance)                      Y     or     N

 

10.  Do you have any relatives living in the area?                                                       Y     or     N

      Check below the assistance your relatives provide for you and your children.

Housing		Financial Help
Transportation		Other
Child Care		None

 

11.  Do you have medical insurance?                           Y     or      N

 

12.  Do you own a personal computer?                       Y     or     N

 

EDUCATIONAL:

 

13.  What college or university will you be attending? _____________________________________________

14.  Major: ______________________________________  Number of Hours Enrolled: __________________

Anticipated Graduation Date: ____________________

 

15.  Please list below the schools you have previously attended (Grade School, High School, College, Vocational, Military, etc.)

 

School Name	Date Attended

 

FINANCIAL AID:

 

1.      Have you applied for Federal Financial Aid?        Y      or       N

2.      Have you received Pell?                                       Y      or       N    

      Complete the following for the academic year for which you are applying:

 

Semester:	Pell Amount	Loan Amount	SEOG Amount	AR State Scholarship	Workstudy	Miscellaneous Aid
Fall 20___
Spring 20___
Summer 20___

 

3.      For what types of costs do you anticipate using the Single Parent Scholarship? _____________________________________________________________________________________

 

4.      Have you previously applied for a Single Parent Scholarship?   Y     or      N

 

FINANCIAL INFORMATION:

 

Please list all sources of income you are currently receiving in Column A and income you expect to receive during the next 12 months in Column B.

INCOME	Current Income			Next 12 Months
	Column A			Column B
	$ Per Month	$ Per Year		$ Per Month	$ Per Year
Friends/Family..………………
Employment…………………..
Workstudy……………………..
Reserved Armed Forces…….
Unemployment Benefits……..
Social Security………………..
Rehabilitation………………….
HUD Rental Assistance……...
TEA…………………………….
Child Support………………….
Food Stamps………………….
VA………………………………
Other (Please List)……………

 

EXPENSES

 

What are your average “out of pocket” monthly expenses? (Please list dollar amount)

Expense	Total Amount Spent per Month
Housing
Utilities (gas, water, electric, phone)
Food
Transportation & Car Maintenance
Insurance Coverage
Loan Payments
Clothing
Medical (checkups, dentists, etc.)
Child Care
Household Goods
Others (Please List)

 

EMPLOYMENT INFORMATION:

1.      Will you be working while you attend school?   Y     or      N

2.      If yes, how many hours each week will you work? _________________

3.      Please list your employers for the past five years beginning with your most current:

Name of Employer	Address	Job Title	Date (From – To)

     

4.      If you have not been employed outside of the home, list your major home and community activities for the past five years.  _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

·        Please have three people send letters of reference to the Scholarship Committee who are familiar with your life experiences and character.  Forward letters to the Scholarship Committee.

·        Please attach a personal statement explaining why you chose this particular course of study and what you hope to achieve.  Feel free to include any information about yourself which might be helpful to the committee in its evaluation.

·        Please attach a transcript or copy of grades from high school, GED or college record to this application.