JUBILEE GRANT Student Application OSTC 2016-2017 Academic School Year ________________________________________________________________

School Name

STUDENT INFORMATION Name:

Phone (If Applicable)

Date of birth

Gender:

Email (If Applicable)

Ethnicity:

 Male  Female Grade in September 2015

 Hispanic  Native American  Other

 African-American  Asian  Caucasian Name of School District in which you reside Public School that student is eligible to attend

Student is:  New to this school in 2016-2017 school year................................................................................................. Yes  No  If yes, name school student attended in 2015-2016 ___________________________________________________________________  Returning to this school from ANY previous school year in which he/she received a Jubilee Scholarship . Yes  No  If yes, the last year the student received a Jubilee Scholarship was ___________________________________________________

HEAD OF HOUSEHOLD INFORMATION Name:

Street Address:

Relationship to Student

2014 Adjusted Gross Income [Household Income] $

(e.g., Mother, Father)

City, State, ZipCode:

Phone:

Email:

INCOME REQUIREMENT: Your 2015 Adjusted Gross Income (AGI)–as shown on the federal tax return on which the student is claimed as a dependent–may not exceed $44,000. And married parents who file separately must total and document the AGI of both returns. Please write a paragraph about how this scholarship will benefit your child:

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HEAD OF HOUSEHOLD INFORMATION (CONTINUED) The following question is optional and does not affect your child’s scholarship qualification: May Children’s Jubilee Fund contact you to ask about how your child is benefiting from the education he or she is receiving? ............................................................................................................................................................. Yes  No 

I hereby certify that, to the best of my knowledge, the information provided on this application is true and accurate. I have attached a copy of my 2014 IRS Form 1040/1040A/1040EZ* (or my state tax return) as documentation of my income. Please do not submit only Forms W-2 and/or Forms 1099 as proof of income. Parent/Guardian Signature

Date

*If you are not required to file a federal tax return, please provide documentation showing total income (including alimony, child support, disability income, pension payments, public assistance, social security, supplemental SSI income, and wages).

SCHOOL ADMINISTRATION INFORMATION Note to Administrator: A student is eligible if he/she:  resides within the attendance boundary of a low-achieving public school in Philadelphia, PA; Norristown, PA; or Chester-Upland, PA, and  is new to the school in the 2016-2017 school year (or received a Jubilee scholarship at your school in some previous year), and  has parent(s) or guardian with an Adjusted Gross Income of $44,000 or less.

This student is under consideration for a Children’s Jubilee Fund scholarship. To the best of my knowledge, the information on this application is true. Head of School’s Signature: ____________________________________________________________________________ Date: ____________________________________________________________________________

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