Equipment Program

Sunday, February 3, 2019

Financial Aid Form

Information

Parent / Guardian 1 Name:_______________________________ Date of Birth:_____________
Address:________________________City:_____________State:______Zipcode:___________
Home Phone:________________________Cell Phone:________________________________
Email:_______________________________________________________________________
Marital Status: Married Single Divorced Separated Widowed
Place of Employment:___________________________Job Title:________________________
Name of Supervisor:____________________________Work Phone:_____________________
How long have you worked there?_____ years months weeks Currently Unemployed
Parent / Guardian 2 Name:_______________________________ Date of Birth:_____________
Address:________________________City:_____________State:______Zipcode:___________
Home Phone:________________________Cell Phone:________________________________
Email:_______________________________________________________________________
Marital Status: Married Single Divorced Separated Widowed
Place of Employment:___________________________Job Title:________________________
Name of Supervisor:____________________________Work Phone:_____________________
How long have you worked there?_____ years months weeks Currently Unemployed
Household gross annual income_______________________
Dependent Children in the Home
1.____________________ DOB:___________ applying for NGSA assistance Yes / No
2.____________________ DOB:___________ applying for NGSA assistance Yes / No
3.____________________ DOB:___________ applying for NGSA assistance Yes / No
4.____________________ DOB:___________ applying for NGSA assistance Yes / No
5.____________________ DOB:___________ applying for NGSA assistance Yes / No

Documentation
Please check which documentation you have attached (must provide 2)
copy of payroll check stub (include last 2 stubs)
copy of most recent Federal Income Tax Return
unemployment card, check stubs and statements
statement from your local DHS office verifying benefits for the last 6 months
I verify that all information is true to the best of my knowledge. I understand that if I knowing
give wrong information, I will be disqualified for the NGSA assistances.

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