SFJMCS Financial Assistance Application Form

What is the combined/total annual household income from all sources ie. child or spousal support, etc.: Check the appropriate box. *

Rows	Under $20,000	$20,000-$30,000	$30,000-$40,000	$40,000 and Up
Income

The items listed below are to be transferred from your 1040: (Includes spouse's information is applicable).
Tax Filing Status
Number of Dependents*
Line 6C on 1040, Line 5on 1040 EZ or Line 6C on 1040A.
Adjusted Gross Income*
Line 37 on 1040, Line 4 on 1040 EZ or Line 21 on 1040 A.
Other Sources of Income (child support, spousal support, retirement, investment, SSI, etc.)*
Total/Combined Income*
Line 22 on 1040 or Line 15 on 1040 A.
Please Note: Financial assistance is not guaranteed. It will be determined based on the financial need. Assistance will be given based on the availability of funds and level of need. Please write a descriptive account of why your family is in need of financial assistance. This application is confidential. The information on the form will not be shared. We will notify applicants of the award decision and/or amount within 2-4 weeks. Need is the most important priority for the Financial Assistance consideration.
Please make a statement describing why your family is in need of financial assistance. Include any special circumstances. The more detail that you provide will help us to determine your level of need and eligibility for assistance.*
To be Completed by Parent / Guardian
By signing this document, I agree that the information is accurate.
Parent / Guardian Name*

First NameLast Name
Parent / Guardian Signature*
Proof of Income (2022 Tax forms & Last 4 check stubs): *

Cancelof
Should be Empty:

Financial Assistance Application 2023-24