Preschool Family Application 2011-2012

Indian Creek Valley Christian Family & Children’s Center Tuition Preschool Grant Program

Form CCS-2


Financial Information

All parents and/or guardians who claim scholarship recipients as dependents must report income on the form with supporting documentation.


Head of Household Name:___________________________________________________________________________________

                                           First Name Middle Initial or Name Last Name

 

Number of people in household: Adults_____________________            Children__________________________


Please list children in your household applying for ICVCFCC Tuition Preschool Grant Program:

 

Children’s Names:        ________________________________             _______________________________________

 

                                  ________________________________             _______________________________________


INCOME SOURCE

FATHER

MOTHER

OTHER

1. Adjusted Gross Income

     reported on current 1040***

 

 

 

2. AFDC or ADC

 

 

 

3. Other Public Assistance

 

 

 

4. Any Other Additional Income

 

 

 

5. Total Individual Income (sum of each column)

 

 

 

                                                                                                       Total Household Income

                                                                                                       (Sum of Row 5)            $_________________________


***To verify income please attach to this application copies of your current year Form 1040 tax return and other supporting proof of income. Married couples filing separately must attach both forms. If you would like a free coy of your 1040, please call the Internal Revenue Service at 1-800-829-1040.


I certify that all the information provided on this application is true and complete to the best of my knowledge. I agree to provide proof that the statements made in this application are true and I acknowledge that failure to do so will invalidate the Tuition Grant Program.

_________________________________            __________________________________          ___________

Print Name of Parent/Guardian                         Signature of Parent/Guardian                           Date

 

_________________________________            __________________________________          ___________

Print Name of Parent/Guardian                         Signature of Parent/Guardian                           Date

 

Complete this section only if you do not file a 1040 

(Parents/guardians using a notary must also provide supporting financial information.)


I certify that this applicant has provided me or this notary service with adequate proof of income and that to my knowledge the financial information provided on this form is true and complete.

 

______________________________________                          ________________________

Notary Signature                                                                    Date

 

______________________________________                                                                        Space for Notary Stamp

Notary Name Printed