Please note: This application will not be read unless it is fully completed.

  Diocese of Kansas City-St. Joseph

 CENTRAL CITY SCHOOL FUND

             ELEMENTARY SCHOOL SCHOLARSHIP APPLICATION

 SCHOOL for 2011-12:_____________________________DATE OF REQUEST:_________________

Part I: Student Information

Part II: Parent/Guardian Information

Check all that apply.

Student lives with:  9 Father  9 Mother  9 Guardian  9 Stepfather  9 Stepmother  9Grandfather  9 Grandmother

Circle one:   Father    Mother    Stepfather    Stepmother    Guardian

                    Last Name                                                                                                                            First Name                                                                                                                 Middle In

City                                                                                           State                Zip                                             Home Phone

If not working, state why: 

Circle one:   Father    Mother    Stepfather    Stepmother    Guardian    

If not working, state why: 

PART III: Other Dependents (Not including student(s) listed above)

¨                  Please list those you send money to as dependents.

Last Name                                                                                 First Name                                                      Age                       School or Place of Employment                            Tuition/Child Care 

PART IV: Family Income/ Assets                                                    2012                                                                      2011 (estimated)

Part V: Income Verification: One of the following must accompany this application.

·       A copy of EACH family member’s completed and signed Federal Income Tax Return (Form 1040 or 1040A) for 2009.

·       W-2 forms for each family member from 2010.

·       A written verification of welfare status prepared by your welfare officer on office stationary.

·       Employer letter verifying salary.

** Note: Income verification forms remain confidential and will remain in the Central City School Fund office.

Part VI:  Other Tuition Assistance:

Please list any tuition assistance other than CCSF that you currently receive:

Part VII: Family Expenses

Part VIII: Special Circumstances

Please describe any special circumstances regarding your family situation and financial expenses.  Tell us why a scholarship would help your family.

Part IX:  List 3 Reasons why you are choosing a Catholic School.

Part X: Signature

I declare that the information on this form is, to the best of my knowledge, complete and accurate.  I authorize the transmittal of the information on this form to the school(s) to which my child(ren) is applying for tuition assistance.  I agree, if requested, to send additional information to support or verify statements on this form.