Application for Tuition Assistance 22-23
Basic Information
Musician's Name
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First Name
Last Name
ESYO Ensemble(s)
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Parent/Caregiver Name
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First Name
Last Name
Parent/Caregiver Email
*
example@example.com
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Financial Information
1a. What is your total adjusted gross income? Actual Last Completed Tax Year
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From 1040: line 37, or form 1040A: line 21. Include a combined TOTAL of adjusted gross income for ALL supporters.
1b. What is your total adjusted gross income? Estimated Current Tax Year
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2a. Non-taxable income and/or benefits (listed below) received by your family: Actual Last Completed Tax Year
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2b. Non-taxable income and/or benefits (listed below) received by your family: Estimated Current Tax Year
3a. TOTAL INCOME: Actual Last Completed Tax Year
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Add Line 1a and Line 2a on this form.
3b. TOTAL INCOME: Estimated Current Tax Year
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Add Line 1b and Line 2b on this form.
4. COVID-19: Please list any COVID-19 related or other extenuating circumstances and subsequent financial implications that show your need for financial aid.
5. Household size
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Please indicate the total number of persons living within your household who are dependent on this income:
6a. Unemployment: Enter the number of months the primary wage earner was unemployed during the actual last completed tax year and the approximate monthly impact:
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6b. Unemployment: Enter the number of months the secondary wage earner was unemployed during the actual last completed tax year and the approximate monthly impact:
*
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Upload Supporting Documentation
Upload a copy of your most recently filed IRS Income Tax Return (1040 or 1040A).
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This form must be accompanied by a copy of the first 2 pages of each supporter’s most recently filed IRS Income Tax Return (1040 or 1040A). Please use a dark permanent marker to conceal any social security numbers listed on all included forms. Musician for whom assistance is sought MUST be listed as a “Dependent” on line 6c of the included 1040 or 1040A.
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Additional Tax Documentation
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Signature(s)
I hereby affirm...
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By checking this box I hereby affirm that the information contained within this form and its attachments are accurate, true, and complete to the best of my knowledge.
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Print Full Name
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Date
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Relationship to Musician
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Phone Number
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