Guardian Information
Parent Name
First Name
Last Name
Current Marital Status
Employment Status
Employer
Occupation
Relationship to student
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2nd Guardian Information
If single parent/guardian skip this section
Name
First Name
Last Name
Current Marital Status
Employment Status
Employer
Occupation
Relationship to Student
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Income
Size of household (Adults)
Size of household (children)
Adjusted Gross Income (AGI) from the most recent tax return
Co-Applicant/Spouse AGI if files separately
Total paychecks of the past two months
Paycheck amount last month
Do you receive any government assistance:
Total amount of assistance received:
Frequency received:
Any estimated income changes:
Total estimated change:
Reason for change
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Expenses
Monthly rent/mortgage (include principal, interest, taxes, and home insurance):
Do you own a second home:
Vehicle Make/model
Monthly payment on the vehicle
2nd Vehicle Make/model (if applicable)
Monthly Payment on 2nd vehicle
Total debt
Minimum monthly payment on debt
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Assets and Liabilities
Value of cash, savings and checking accounts:
Value of stock, bond investments, mutual funds, and or certificates of deposit:
Value of retirement accounts
If you own your home how much do you owe:
If you own your home, how much is it worth:
Students Name
Amount you can contribute towards tuition for this student
Other possible areas where you or your student may be able to contribute
Availability times to contribute
We certify that to the best of our knowledge, this information is true and correct:
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Section 1: Parent(s)/Guardian(s) (Applicant/Co-Applicant) Information
Name:
First Name
Last Name
Current Marital Status:
Employment Status:
Relationship to Student(s):
Occupation:
Employer:
Name:
First Name
Last Name
Current Marital Status:
Employment Status:
Relationship to Student(s):
Occupation:
Employer:
Section 2: Income
Supporting documentation may be requested
Size of household: Adults:
Children:
Adjusted Gross Income from most recent tax return:
Paycheck amounts last two months:
Adjusted Gross Income from most recent tax return (if co-applicant files separately):
Paycheck amount last mo:
Does applicant or co-applicant receive any of the following? Child support, Social security benefits not taxed (SSI), Temporary Assistance for Needy Families (TANF), Welfare and/or Aid for Families with Dependent Children (AFDC/ADC), Food Stamps, Tuition support from friends/relatives/employer Workers' Compensation, Other nontaxable income (housing allowance, foster allowance, VA benefits, etc)
Yes/No:
Total amount received:
Frequency received:
Does applicant or co-applicant anticipate any change in income for the following year?
Yes/No:
Total estimated change:
Reason for change:
Section 3: Expenses
Supporting documentation may be requested
Monthly rent or mortgage (include principal, interest, taxes, and home insurance):
Do you own a second home? Yes/No:
Vehicle Information: Leased/Owned (Paid off or not)
Vehicle 1 Make/Model:
Year:
Monthly payment:
Vehicle 2 Make/Model:
Year:
Monthly payment:
Vehicle 3 Make/Model:
Year:
Monthly payment:
Total other monthly loan payments:
Total monthly medical expenses:
TOTAL MONTHLY EXPENSES:
List significant annual expenses not reflected above:
Expense:
Amount:
Expense:
Amount:
Expense:
Amount:
Section 4: Assets & Liabilities
Value of cash, savings, and/or checking accounts:
Value of stock, bond investments, mutual funds, and/or certificates of deposit:
Value of retirement plan assets - 401(k), 403(b), and/or IRAs:
What is your and/or your spouse's annual contribution to retirement plan assets?
If you own your home, the amount you owe:
If you own your home, the estimated value:
We certify that, to the best of our knowledge, the above information is true and correct:
Applicant:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Co-Applicant:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Office Use Only:
Child's Name:
First Name
Last Name
How much can be contributed per month?
Child's Name:
First Name
Last Name
How much can be contributed per month?
Child's Name:
First Name
Last Name
How much can be contributed per month?
Areas where applicant/co-applicant can contribute:
Availability: Daily:
Weekly:
Monthly:
Notes:
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Should be Empty: