2021-22 Financial Assistance Application

Financial Assistance Application
***LATE APPLICATIONS - Applications submitted after 4 p.m. on 3/01/2021 will be reviewed after 3/22/2021 and subject to the availability of funds.
Financial Assistance Application Checklist

Please review the Financial Assistance Application Checklist by clicking on the blue text below.
Please scroll down to read both pages below.
Prior to filling out this application please make sure you have the following:
a) 2019 completed individual tax return (PDF format)

*If your 2020 tax returns are completed please upload those instead of the 2019 tax returns (PDF format)

b) 2020 W-2 forms for all guardian(s) (PDF format)
c) Debit or credit card for $25 Financial Assistance Application processing fee
***The above documents are required to submit this form. This form must be completed in one sitting. Incomplete applications cannot be processed.***

Due Dates:
The completed application and supporting documents for current families are due no later than 4 p.m. on March 1, 2021. New applicant(s) to HBHA are required to submit all documents by communicated deadlines.

Note: Fields below may have directions or instructions to the right when you hover over it.
Amount of Financial Assistance Request

How much are you requesting in Financial Assistance for all student(s) attending HBHA during 2021-22 academic year?
*
(Do not enter how much you want to pay for the 2021-22 school year.)

Primary Contact Information

Primary person HBHA will contact during the financial assistance process.
Primary Contact *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Relationship to student (s) *
Contact and Demographic Information

Parent/Guardian(s) contact information
Number of student(s) that you are applying for Financial Assistance for? *
Name of student(s) and grade(s) *
Marital Status of Parent *

Married Divorced Separated Widowed Single
Name of Spouse/Partner

First Name Last Name
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Name(s) and age(s) of other dependent children that the household supports excluding those listed above (birth through college)(Enter N/A if this does not apply) *
Name(s) of other dependent(s) living in the household and relationship to student. I.E. Grandparents or other relatives. (Enter N/A if this does not apply) *

Jewish Community Programs/Services
Have you or any member of your family received an adjusted fee for any program, membership, or service within the Jewish Community (e.g. JCC after school care)? *

Yes No
If yes, list program(s), date, full fee requested and amount you paid below.

Community Involvement
Please describe your family's involvement in the Kansas City Jewish community or Kansas City community, in general. *
Please describe your family's involvement in the HBHA community. List activities/efforts - for example, do you volunteer at HBHA, serve on the Board of Directors, are you a member of PTO, been a room parent, etc. *

Employment Information
Please indicate the anticipated amount of gross earnings your household will receive during the 2021-22 school year(if not applicable enter "0.00"):
Occupation of the Head of Household (Job Title) *
Gross Income Earned during 2020 *
Enter gross income earned during 2020
Projected Gross Income for 2021 *
Enter gross income that you anticipate earning in 2021
Are you self-employed? *

Yes No
Business Name *
Gross Income earned during 2020 *
Enter the gross income amount earned from all income sources during 2020.
Business Phone Number *

Area Code Phone Number
Business Address *

Street Address

Street Address Line 2

City State

Zip Code
Occupation of the Spouse/Partner (Job Title)
Gross Income Earned during 2020
Enter gross income earned during 2020
Projected Gross Income for 2021
Enter gross income you anticipate earning during 2021
Are you self-employed?

Yes No
Business Name
Business Phone Number

Area Code Phone Number
Business Address

Street Address

Street Address Line 2

City State

Zip Code
Gross Income earned during 2020
Enter the gross income amount earned from all income sources during 2020.

Projected Gross Income for 2021
Enter the gross income amount you anticipate that you will earn during 2021.
Additional Financial Information

2021-22 School Year Income
Government Assistance
SSI / Disability
Distribution from Trust Funds
529 Plan Distribution
Interest / Dividend Income
Other Income (Explain in Below)
If other income, explain:
If you are divorced or separated, please answer the following questions (Enter "0.00" if this does not apply to you):
Child Support
Maintenance / Alimony
Other individual(s) who regularly help pay for family expenses:
Relationship to Student(s)
Annual Amount Given
Relationship to Student(s)
Annual Amount Given
Explain any short term circumstances that are affecting your finances and include how long this situation might last (i.e. divorce, loss of job, short term medical problems). If not applicable, input N/A. *
Explain any long term circumstances (any situation that may extend to 3 years or longer) that you would like the financial assistance committee to consider during their review process. If not applicable, input N/A. *

Tax Information
Enter Total Income from 2019 Tax Return (Line 7b on 1040 Form) *
For Individual / Joint Tax Filers
Attach 2019 Tax Return *

Browse Files

Cancel of
Attach 2019 Tax Return (Married Couples Filing Separately)

Browse Files

Cancel of
Attach 2020 Tax Return (If Completed/Filed)

Browse Files

Cancel of
2020 W-2 Form or Copy of Last Paycheck Stub

Browse Files

Cancel of
Additional 2020 W-2 Forms

Browse Files

Cancel of
Self-Employed Attach Most Recent Financials

Browse Files

Cancel of

Household Expenditures

What amounts do you anticipate paying for the following items during the 2018-19 school year: (Enter "0.00" if you do not have any expenses for that category, enter "N/A" in other explanation if it is not applicable)
Rent or Mortgage
Transportation (Vehicle Payments)
Maintenance / Child Support
Childcare Expenses
College Tuition & Fees
Elderly Care
Other (explain below)
If other, list below

Statement of Unusual or Temporary Circumstances
Is your family applying for financial assistance due to an unusual or temporary circumstance? For instance are there unusual medical expenses or loss of income. Use this as an opportunity to explain to the financial assistance committee why you need financial assistance. An explanation of need will assist the committee in granting financial assistance awards. *

I/We declare that the information contained in this form, to the best of my knowledge and belief, is true, correct, and complete. I/We understand that funds available for assistance are limited and that the amount of assistance, if any, will be based on financial need and available funds. I/We also understand that I/We will be required to make electronic payments through FACTs, if I/We accept the Financial Assistance Award. *

Yes, I/We have read, understand, and accept the above statement.
Name of Guardian (Electronic Signature) *

First Name Last Name
Date *

Month Day Year
Date
Name of Guardian (Electronic Signature)

First Name Last Name
Date

Month Day Year
Date
I agree that the electronic signature appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Clear
Financial Assistance Application Fee

Financial Assistance Application Fee *

Application Fee $ 25.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Financial Assistance Application

Financial Assistance Application Checklist

Amount of Financial Assistance Request

Primary Contact Information

Contact and Demographic Information

Jewish Community Programs/Services

Community Involvement

Employment Information

Additional Financial Information

Tax Information

Household Expenditures

Statement of Unusual or Temporary Circumstances

Financial Assistance Application Fee