St. Ignatius of Antioch School Tuition Assistance Program 2018-2019 Financial Disclosures Parent/Guardian #1 Name

Phone Number

Parent/Guardian #2 Name

Phone Number

St. Ignatius Student #1 - Name, Grade 2018-2019

St. Ignatius Student #2 - Name, Grade 2018-2019

St. Ignatius Student #3 - Name, Grade 2018-2019

St. Ignatius Student #4 - Name, Grade 2018-2019

Please provide the following:

1) BLOCS application for 2018-2019 school year (if applicable) 2) 2017 tax return (2 page 1040, or similar, schedules not necessary)

In addition to the above documents, please provide the following information:

Gross Income - include wages, investment, and other income Annual

Monthly

Sources: 1) 2) 3) 4)

Expenses

Annual

Mortgage - primary Mortgage - secondary or Rent for primary residence

Monthly

Charitable Contributions - Total Donations to St. Ignatius Parish

Alimony and/or court appointed child support

Other private school tuition (primary/secondary grades) College tuition & fees

Other significant expenses (e.g. medical, childcare) 1) 2)

Assets and Debt

Bank Account Balances - Total (Checking/Savings/Money Markets)

Investments (Stocks/Bonds/etc. EXCLUDE RETIREMENT FUNDS) Estimated Market Value

Related Debt Balance

Primary Residence

Other Residence(s)

Vehicles 1) 2)

Other Information Yes Did you apply for BLOCS for 2018-2019 school year? Are you a St. Ignatius School alumni?

No

Would you consider yourself an active St. Ignatius parishioner and/or school parent? If yes, please briefly describe your involvement in our parish ministries and/or school.

Is there anything else that should be considered by the committee and pastor in their decision regarding tuition assistance for your family? Please describe below.

Parent/Guardian Signature

Date

Parent/Guardian Signature

Date

NOTE: The information disclosed on this form as well as in all supporting documents will be kept confidential and only used as necessary to aid the Pastor and his advisors in assessing the financial need of the family.