Family and Income Earner

Application for Financial Assistance
2013 / 2014 Academic Year

Please read and review the form and the instructions carefully before you fill it in and do not leave any boxes blank.

PLEASE PRINT IN BLOCK LETTERS

I. APPLICANT’S PERSONAL PROFILE

1 Name: ___________________________________________________________________________________
Family First Middle

2 Gender: Male Female

3 Date of birth: _____________/______________/______________ Month Day Year

4 Intended date of admission: Fall’13 Spring’14

5 Citizenship: _________________________________
6 Country of residence: _________________________
7 City: _______________________________________

II. FAMILY INFORMATION

8 In answering the following question, please refer to your biological parents
8a Parents’ current marital status (check only one box): Married Divorced Mother living, father deceased Father living, mother deceased Parents not married Domestic Partnership Other________________________ (Please specify)
9 In the definition of family below, use the current family members (step-parents, if needed)
10 How many persons, including the applicant, are dependent upon the family income? (i) Relationship to applicant (ii) Age
10a Income earner A. ____________________________ _________________
10b Income earner B. ____________________________ _________________
10c Income earner C. ____________________________ _________________
10d Other Member D. ____________________________ _________________
10e Other Member E. ____________________________ _________________
10f Other Member F. ____________________________ _________________

11 List any dependents who are in school or university:
11a Name: _________________________ Name of school/university: __________________________________
Annual cost to attend: ________________ Family contribution: