Name *
Name
Date of Birth *
Date of Birth
Parent/Guardian Name *
Parent/Guardian Name
Spouse Name *
Spouse Name
Address *
Address
Phone *
Phone
Overflow/Plus Eligibility
The following information will assist us to determine what type of scholarships your child may be eligible for. Be sure to read through each question and note what information is required to be submitted with the application. Failure to send in appropriate documentation along with your application will delay processing time.
1. Is your child transferring from an Arizona public school? *
NOTE: To check YES, your child must have been enrolled in an Arizona public or charter school for at least 90 days of the previous school year.
2. Is your child enrolled in Kindergarten at a private school the 2017-2018 school year? *
3. Is your child currently a part of the Arizona Foster care system? *
4. Is your child a dependent of a member of the United States Armed Forces stationed in Arizona pursuant to military orders? *
5. Is your child currently enrolled in private school and does he/she have a current Individualized Education Plan (IEP) from an Arizona public school or Multidisciplinary Evaluation Team (MET)? Please provide the current summary sheet of the IEP or MET along with your application.
6. Has your child previously received a tax credit scholarship from APSTO or any other Arizona State Tuition Organization in the previous school year (17-18 or prior) and continued to attend private school in Arizona? *
*Note if this scholarship was given by an organization other than APSTO, you MUST provide verification of that award. Please submit a copy of the award letter you received. If you do not have a copy of that award letter, you can have that organization complete the previous award verification form. This form can be attached to your application.
Household Income
Household Income: Please read the following instructions to make sure the form is filled out correctly. The financial information must match your 2018 taxes exactly.
A. Names: List the first and last names of every person living in your household (adults and children) everyone must be listed whether or not they receive income or not. If no income is received mark the no income box for that entry
B. Gross YEARLY Income: Following each person’s name, list the type of income received on a YEARLY basis.
*Earnings from work: List gross income from work (wages, salaries, tips, commissions). This is not the same as take home pay; it is the amount earned before taxes and deductions. Gross earnings should be listed on your pay stub. If self-employed, you may report income after expenses (your own business, freelance work farm, or rental property).
*Welfare, Child Support, Spousal maintenance: including – TANF, General Assistance, General Relief, etc. NOTE: Food Stamps and FDPIR benefits are not included as income.
*Pensions, Retirement, and Social Security: include – Supplemental Security Income (SSI), Veteran’s (VA) benefits, and disability benefits.
*All Other Income: Include: Worker’s Compensations, unemployment, strike benefits, net rental income, annuities, net royalties, interest, dividend income, cash withdrawn from savings, income from estates, trust and/or investments, regular contributions from people who do not live in your household, and ANY OTHER INCOME. You do not have to include military or combat pay/allowances as income.
Names - You must list EVERYONE in your household *
Names - You must list EVERYONE in your household
1.
$
$
$
2.
$
$
$
3.
$
$
$
4.
$
$
$
5.
$
$
$
6.
$
$
$
(Summary of everyone listed above)
$
C. Foster Child: if this an application for a child who is the legal responsibility of a welfare agency or court and is currently living in your household please provide the following information about the child (please list additional foster children on a separate Financial info Form)
Child's Name
Child's Name
$
Typed Name reflects Signed Document:
Date *
Date