FSA Scholarship Funds Request
ALLOW 15 DAYS FOR FSA TO PROCESS PAYMENT TO YOUR SCHOOL
Name
*
First Name
Last Name
This is my:
*
1st installment request
2nd installment request
3rd installment request
4th installment request
I won this scholarship in
(month/year)
*
.
How many credit hours will you be taking this semester?
*
(required minimum of 6)
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
School ID
*
Social Security Number
*
School you plan to attend next semester
*
School Contact Person
*
School Phone Number
*
Please enter a valid phone number.
School Address - Be sure to ask your school if there is a different address for Scholarship Payments
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Proof of Registration
*
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Attach a copy of your upcoming class schedule. You must be registered for a minimum of six (6) credit hours.
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of
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