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CSMA Scholarship Application p.2
   
 
Please Complete & Provide the Requested Items Below
1.
Copy of most recent Federal Income Tax return(s) for all household members and/or non-household member who claims the student as a dependent.
2. Current Gross Household Income (choose appropriate column(s):
Weekly
Bi-Weekly
Monthly
  a) Wages or Salary earned $ __________ $ __________ $ __________
  b) Public Assistance/TANF $ __________ $ __________ $ __________
  c) Alimony and/or Child Support $ __________ $ __________ $ __________
  d) Social Security $ __________ $ __________ $ __________
  e) S.S.I. $ __________ $ __________ $ __________
  f) Other income (pension, disability, etc.) $ __________ $ __________ $ __________
  g) Self-Employment Income $ __________ $ __________ $ __________
  h) Income earned by dependent children $ __________ $ __________ $ __________
3. Please attach photocopied documentation of each source of the income listed above. Circle the letters below of items attached.
  a) Most recent pay stub
  b) Letter from Dept. of Social Services stating amount of award
  c) Proof of child support, maintenance and/or alimony
  d) Proof of Social Security income or survivor’s pension
  e) Official proof of S.S.I. income
  f) Official proof of pension, disability, unemployment or other compensation
  g) Statement of anticipated income from self-employment
  h) Documentation of income earned by dependent children
4. Does any other person (not accounted for in the above catagories) contribute directly towards CSMA tuition for any of the students listed on this form?
  Yes _____ What is the annual amount of their contribution? $ ___________
  No ______    
5. Please describe and provide documentation for any significant changes in your financial situation during the current year, since filing the tax return referred to above.
  _____________________________________________________________________________
  ______________________________________________________________________________
  College & University Students - If you can be claimed as a dependent, you must provide the appropriate documentation, as requested above, from the person who, for tax purposes, can claim you as a dependent.
  To the best of my knowledge, the information given on this form is complete and correct.
  _________________________________________ Date: _______________
  Signature of Person Completing this Form