1. 2012 Scholarship Application Greater Lafayette www.ywca.org/lafayette

2. To apply for a scholarship, you need to do the following: 1. Complete the scholarship application with current and accurate information. 2. Please enclose, in an envelope, your application and photocopies (not originals) of all the following personal financial documents that reflect your current household income:  *Most recent prepared Federal Income Tax return (1040 with w-2’s and all schedules)  *1099-R’s and/or Social Security Benefit statement for previous year  Two pay stubs for each person in household’s income from current Employer  Food Stamp statement  Other income verification  If in college; class schedule with an account summary (this must be resubmitted each semester) *This is required if you have filed taxes or received SSI for the most current previous year. If you do not have a copy of your tax return, you may obtain one by calling the IRS at 1-800-829-1040 or visit their website at www.irs.gov for a free transcript of your tax return or if you did not file taxes, you can request a nonfiling verification letter. 3. If none of the above are applicable to your situation and/or you do not have at least two of the above documents, please write a letter explaining your circumstances. Please include what you feel you can afford for the program and/or membership that you are applying for and any volunteer service you can provide. Scholarships are good for 6 months unless you are notified otherwise. Applications will be reviewed only after all information is submitted and the application is filled out completely. When all necessary documents are turned in with your application, please allow 7-10 business days for the application to be processed. If you have any questions regarding your application, please feel free to call 765-742-0075 and ask for the Finance Director. Scholarships will be awarded to an individual / family only once in a 12-month period. Thank you. Scholarship Application Instructions 02

3. 03 2012 Family Income Guidelines

4. 04 YWCA Greater Lafayette Scholarship Application – Household Information Please print or type all information Adult in Household (First name)__________________________ (Last)___________________________ Address _______________________________________________________________________ City ___________________________________ State ________ Zip Code ____________ Home Phone ___________________________________ Date of Birth _______________________ Employer ___________________________________ Work Phone _______________________ Full-time student? _______ If yes, where? _________________________________________ Second Adult in Household Full Name __________________________________ Date of Birth _______________________ Employer ___________________________________ Work Phone _______________________ Full-time student? _______ If yes, where? _________________________________________ List full names and ages of all dependents in your household. Proof of household members may be required. Full Name Date of Birth School (if applicable) __________________________________________ ____________ _______________________ For Internal Use Only Date application received _______________ Application received by ______________________ Enclosed:  Tax Return  2 Pay Stubs  Food Stamp Statement  Child Support / Alimony  Other Income Verification  Class Schedule Applying for:____________________________________________ Full Program Fee _____________ Date Granted ________________ Expiration Date _____________ Scholarship Approved (circle one) 1.100% / $5 weekly fee 2. 50% / $40 weekly fee 3. 25% / $20 weekly fee Date Notified ________________ Agreement Form signed & returned _____________

5. 05 YWCA Greater Lafayette Scholarship Application – Household Information Income Your Net Monthly Salary $________________ 2nd Adult’s Net Monthly Salary $________________ Unemployment $________________ Retirement $________________ Social Security $________________ Disability $________________ Child Support $________________ Alimony $________________ Food Stamps $________________ Other (_______________) $________________ Total Monthly Household Income$________________ Additional Information Please check what you are currently applying for: Program: Program:  Summer Day Camp  Y-Dance  Other ___________________________ To better serve you, please share what you hope to gain from your YWCA program: ________________________________________________________________________________________ How did you hear about the Scholarship Program?  Newspaper  Mailing  YWCA Employee  Friend/Family (name)_____________________  Other________________________________________ Please read and sign below: (Signature is required for application to be considered valid.) Scholarships are good for 6 months unless you are notified otherwise. If the YWCA finds that any information given in your application is false, your scholarship will be terminated and full price will be charged or membership/program will be cancelled. I verify that all the information submitted is correct, complete and accurate. I understand that additional information may be requested from the YWCA Greater Lafayette in order to make a final determination. Applicant’s Signature: ____________________________________________ Date: _________________