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Financial Aid Application
2015 CTY Summer Programs
This application is confidential and will be reviewed only by appropriate CTY
Financial Aid Checklist
You must provide the following information in order to be considered for financial aid from CTY:
Completed and signed 2015 CTY Summer Program Application.
Completed and signed 2015 Financial Aid Application.
2014 income documents: Signed copy of 2014* federal income tax return (including schedules A, C, D, E, F and/or Form 4562,
if applicable); all W-2/1099 forms; and documentation of any other non-taxable income, such as Social Security and
child support.
DELETE OR BLACK-OUT ALL SOCIAL SECURITY NUMBERS
Postmark Deadline: March 28, 2015
*If you have not filed 2014 taxes yet, we will accept a signed 2013 federal tax return (including schedules A, C, D, E, F and/or
Form 4562, if applicable) along with copies of all 2014 W-2/1099 forms, or your last pay stub(s) of 2014 and any other 2014
non-taxable income, such as Social Security and child support.
APPLICATIONS WILL NOT BE CONSIDERED FOR A COURSE ASSIGNMENT WITHOUT THE APPROPRIATE INCOME DOCUMENTATION.
Part 1
Student Information
(Please type or print legibly in black ink)
CTY Student ID#:
Name:
Last
First
M.I.
________
Street, Route, or Box
City
State
Zip
Is the Student a U. S. Citizen? ___Yes ___No
If no, please explain:_______________________________________
________________________________________________________
If Student Applicant is not a U.S. Citizen, is he/she an eligible
permanent U.S. resident? ___ Yes ___ No
*If yes, please attach a copy of the student’s permanent resident
Parent Evening Phone Number: (_____) _____________________
card (Green Card).
Parent Cell/Day Phone Number(_____)______________________
Parent Email:___________________________________________
Applying for:
Residential
Commuter at Residential
Day Site
Please check here if you are applying for the Richard B. Kershner Scholarship. (See the 2015 Intensive Studies Summer
Programs for Students in 7th Grade and Above catalog for eligibility criteria.) If applying for the Kershner Scholarship only, you do not have to enclose t
ax forms or other financial information. Postmark deadline: March 24, 2015.
Part 2
Family Information
Parent’s Martial Status: (Check all that apply):
__Single __Married __Separated __Divorced __Widowed __Mother Remarried
__Father Remarried
__Domestic Partnership
Student currently lives with (check all that apply): __Father __Mother __Stepparent __Other_____________________________
Parent 1 Name:______________________________________
Parent 2 Name: _______________________________________
Occupation: _________________________________________
Occupation: __________________________________________
**Total 2014 Adjusted Gross Income:_____________________
**Total 2014 Adjusted Gross Income:_______________________
**(from ALL W-2 or paystub Year-to-Date earnings, business income, Social Security Income, other non-taxable income, etc.)
Parent(s) ESTIMATED 2015 Annual Income:__________________________________________
Excluding the student, list all dependent children in the household. If a dependent is a student, please list name of school and the amount
of financial aid awarded for the 2014-2015 year. Attach additional page, if necessary.
Name
Relationship to Applicant
Age
Name of School
Amount of 2014-2015 Financial Aid
1.___________________________________________________________________________________________________________________________________
2.___________________________________________________________________________________________________________________________________
3.___________________________________________________________________________________________________________________________________
Student’s Name & ID#:______________________________________________________
Part 3
Additional Information
Name of school that the student is attending during 2014-2015:__________________________________________________________
___Public School ___ Charter School ___Private or Independent School ___Other____________________________________________
Is the student on a reduced fee or free lunch plan? Yes______ No_______
Has the student received financial aid for CTY programs in the past? Yes____ For which program?________________________ No______
Does the student have any siblings currently applying for CTY programs? Yes___ No___ If yes, please list student’s name(s) below:
________________________________________________________________________________________________________________
Name(s) of sibling(s) and name(s) of CTY Programs
Part 4
Other Resources
Current value of cash/savings/checking accounts: $ _____________________________________________________________________
Current value of investments (i.e., stocks, bonds, CDs, etc., not including retirement accounts): $________________________________
Current value of any other resources received for the family (including child support): _________________________________________
Will student receive funding for 2015 Summer CTY Programs from any other sources/scholarships? Yes___ If Yes, how much $________________No___
Part 5
Annual Expenses
Do parents own or rent their home? OWN RENT
Tuition paid for other children………………… (documentation required):
Uninsured medical/dental expenses……….. (documentation required):
Student loan repayment………………………… (documentation required):
Other, not including usual living expenses (documentation required):
Part 6
Mortgage/rent payment:____________________/year
________________________________/year
________________________________/year
________________________________/year
________________________________/year
Special Circumstances
On a separate sheet of paper or below, please explain your need for financial assistance and any special circumstances which may affect
your ability to contribute toward the student’s CTY program costs. If you were not required to file a 2013 tax return, or you have not yet
filed a 2014 tax return, please explain here and submit documentation of all income.
Please review the Financial Aid Checklist on the front of this form to ensure you are submitting a complete application.
I certify that all information provided is accurate to the best of my knowledge.
I understand that this is an application for financial assistance and that CTY will verify the information.
___________________________________________________________
Signature of Parent or Legal Guardian
________________
Date
NOTE: Financial Aid funding is limited. An award in a previous year does not guarantee an award this year; a
completed financial aid application must be submitted to be considered for funding each year.