2023-2024 Day School Affordability Grant Application

Day School Affordability Grant Application for K-12

Open for School Year 2023-2024
Please complete the form below to be considered for the Day School Affordabilty Grant. You will need a copy of your 2021 1040 Tax form and W2.

It should take about 10 minutes.

Divorced parents may fill out forms individually, and submit separately. The determination process will begin once both forms are received.

All information submitted through this form is kept strictly confidential. It is visible only to the CFO of Samis Foundation and the Business Manager of the school(s) you select. No member of the Admissions committee will see this information.

Grant determinations will be made in the order they are received.
1. Family Information

Divorced, single, separated or never married parents may submit separately.
Parent 1 (P1)*

P1 First NameP1 Last Name
P1 Email*
example@example.com
Parent 2 (P2)

P2 First NameP2 Last Name
P2 Email
example@example.com
2. School Attendance Information

Please fill out this section for all children attending schools in 2023-2024 that require tuition, including all early childhood programs, independent schools, and college, even if they are not Jewish schools.
Child 1
Child 1 (C1) Name*
C1 School*
C1 If other school, please list here
C1 Grade Level in Application Year*
C1 Date of Birth (MM/DD/YYYY)*
C1 What is the full tuition charged by this school? If you do not know, please estimate.*
C1 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero*

Additional Children
Child 2
Child 2 (C2) Name
C2 School
C2 If other school, please list here
C2 Grade Level in Application Year
C2 Date of Birth (MM/DD/YYYY)
C2 What is the full tuition charged by this school? If you do not know, please estimate
C2 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero
Child 3
Child 3 (C3) Name
C3 School
C3 If other school, please list here
C3 Grade Level in Application Year
C3 Date of Birth (MM/DD/YYYY)
C3 What is the full tuition charged by this school? If you do not know, please estimate
C3 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero
Child 4
Child 4 (C4) Name
C4 School
C4 If other school, please list here
C4 Grade Level in Application Year
C4 Date of Birth (MM/DD/YYYY)
C4 What is the full tuition charged by this school? If you do not know, please estimate
C4 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero
Child 5
Child 5 (C5) Name
C5 School
C5 If other school, please list here
C5 Grade Level in Application Year
C5 Date of Birth (MM/DD/YYYY)
C5 What is the full tuition charged by this school? If you do not know, please estimate
C5 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero
Child 6
Child 6 (C6) Name
C6 School
C6 If other school, please list here
C6 Grade Level in Application Year
C6 Date of Birth (MM/DD/YYYY)
C6 What is the full tuition charged by this school? If you do not know, please estimate
C6 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero
Child 7
Child 7 (C7) Name
C7 School
C7 If other school, please list here
C7 Grade Level in Application Year
C7 Date of Birth (MM/DD/YYYY)
C7 What is the full tuition charged by this school? If you do not know, please estimate
C7 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero
Child 8
Child 8 (C8) Name
C8 School
C8 If other school, please list here
C8 Grade Level in Application Year
C8 Date of Birth (MM/DD/YYYY)
C8 What is the full tuition charged by this school? If you do not know, please estimate
C8 How much financial aid and/or scholarship money do you expect to receive exclusive of this grant program? If none, put zero

3. Income Information

If married filing joint, divorced, single, separated or never married use P1 for 1 tax return. If married filing separate, use both P1 and P2 for 2 tax returns.
Please enter the amounts from your 2021 tax return. Please do not use dollar signs or commas.
Parent 1 (or married filing joint) is first column.
Parent 2 (or married filing separate) is second column.
P1 Adjusted gross income*
P2 Adjusted gross income
P1 Tax exempt interest
P2 Tax exempt interest
P1 Taxable state income tax refund
P2 Taxable state income tax refund
Enter the following AMOUNTS RECEIVED during the year of tax return submitted, but which do not appear on the tax return.
P1 Parsonage*
P2 Parsonage*
P1 Child support received
P2 Child support received
P1 Alimony/spousal maintenance received (if the agreement is dated 1/1/2019 or later)
P2 Alimony/spousal maintenance received (if the agreement is dated 1/1/2019 or later)
Enter the following AMOUNTS PAID during the year of the tax return submitted, but which do not appear on the tax return.
P1 Child support paid
P2 Child support paid
P1 Alimony/spousal maintenance paid (if the agreement is dated 1/1/2019 or later)
P2 Alimony/spousal maintenance paid (if the agreement is dated 1/1/2019 or later)
Retirement plan contributions for the year of the tax return submitted. This may be found on the year-end pay stub and/or listed on the W2.
P1 Elective 401(k) deferrals
P2 Elective 401(k) deferrals
P1 Elective 403(b) deferrals
P2 Elective 403(b) deferrals
P1 Elective 408(k)(6) deferrals
P2 Elective 408(k)(6) deferrals
P1 Elective 457(b) deferrals
P2 Elective 457(b) deferrals
P1 Designated Roth contributions
P2 Designated Roth contributions
Additional retirement plan information. These may be found on the year-end pay stub and/or listed on the W2.
P1 Self-employed SEP, SIMPLE and qualified plans
P2 Self-employed SEP, SIMPLE and qualified plans
P1 IRA deduction
P2 IRA deduction
P1 Nondeductible IRA contributions
P2 Nondeductible IRA contributions
This information is listed on your tax return. Please use the number on the tax return:
P1 Roth IRA contribution, if not already included above
P2 Roth IRA contribution, if not already included above
4. Copy of your tax return and W2s

Please remove passwords to documents prior to submitting. 1. Open the PDF in Acrobat Pro on Windows or Mac. 2. Choose Tools › Encrypt › Remove Security. 3. If the document has a Document Open password, click OK to remove it. 4. If the document has a permissions password, type the correct password in the Enter Password box and then click OK.
Upload your 2021 tax return and 2021 W2s here*

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Application will NOT be reviewed without W2's and tax return.
Cancelof
Is your family new to Jewish day school in Seattle?*
5. Applicant's E-Signature

Thank you for your commitment to your child's Jewish future.
E-Signature*

Clear
Thank you for your commitment to your child's Jewish future. How did you hear about DSA Initiative grants?*
What school year are you applying for?*
What school are you applying for?*
Should be Empty:

Day School Affordability Grant Application for K-12

1. Family Information

2. School Attendance Information

3. Income Information

4. Copy of your tax return and W2s

5. Applicant's E-Signature