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Hackbright Academy Fellowship - Financial Information Form
Fill out this Financial Information Form if you are
• applying for partial financial aid (this is the only thing you will need to fill out)
• applying for a full scholarship through the Hackbright Empowerment Fund. This is one of 2 forms required to apply for a full scholarship. For full scholarship details will be announced at a later date.

About the Partial Financial Aid:
Hackbright offers limited financial assistance for its tuition to eligible students. Based on your financial need, scholarships may be available. You may be eligible for financial assistance if you:
• can show you have financial need
• provide Hackbright with necessary information about your household finances

The process for applying for partial Hackbright financial assistance or full scholarship includes these steps:
• Complete the form herein. (This is the only form you need to complete for partial financial assistance.)
• Send the required supporting documents listed in the Documentation Checklist.
>> We look at your income, assets, and family size to determine the level of assistance available to you.
• We will contact you to tell you whether you are eligible for Hackbright financial assistance.

Documentation Checklist
In addition to the application, you must send copies of any of the following documents that apply to you. If any of the documents are missing, it will delay processing of your application. Send all documents to Laura Gillen, laurag@hackbrightacademy.com.

If You Have Income:
Attach proof of your household income, which may include:
>> IRS Form 1040 or 2016 (Tax return)
>> 2016 pay stubs for the last three months
>> Social Security 1099 forms or award letters unemployment or workers’ compensation award letters
>> If you are self-employed, you must include a IRS Form 1040 Schedule C and/or profit and loss statement.

If You Have No Income:
>> If you have no income, send us a letter of support. The person who provides your support must sign the letter.

Please note that Hackbright has a very limited fund for scholarships. We provide need based financial aid only to those students who demonstrate the most financial need. Please direct all tuition related questions to Laura Gillen, laurag@hackbrightacademy.com.

Section A - Student's Information
Last Name *
Your answer
First Name *
Your answer
Middle Initial
Your answer
Address: Number and Street *
Your answer
Address: City (and country if not U.S.) *
Your answer
Address: State *
Your answer
Address: ZIP Code *
Your answer
Your Date of Birth *
MM
/
DD
/
YYYY
Telephone Number *
Your answer
Email Address *
Your answer
Are you a U.S. citizen? *
If no, check one of the following
Marital Status *
What is your state of legal residence? *
Your answer
What is the highest level of education you have completed? *
Employment Status: Are you currently...? *
Section B - Financial Information
I am requesting financial aid for the following Hackbright session. *
I am submitting this information to be used with the following financial aid programs. *
Check all that apply.
Required
How many people are financially dependent on you? *
Your answer
What was your (and spouse’s) adjusted gross income for 2016? Adjusted gross income is on IRS Form 1040—line 37; 1040A—line 21; or 1040EZ—line 4. *
Your answer
Enter your (and spouse’s) income tax for 2016. Income tax amount is on IRS Form 1040—line 55; 1040A—line 35; or 1040EZ—line 10. *
Your answer
Enter your (and spouse’s) exemptions for 2016. Exemptions are on IRS Form 1040—line 6d or Form 1040A—line 6d; or 1040EZ-line 5. *
Your answer
Please estimate your (and spouse’s) adjusted gross income for 2016? *
Your answer
As of today, what is your (and spouse’s) total current balance of cash, savings and checking accounts? *
Your answer
As of today, what is your (and spouse's) net worth, including investments and real estate? Don’t include the home you live in. Net worth means current value minus debt. *
Your answer
Documentation must be provided to verify income information requested on this form. Please check the type of documentation you will be sending. *
Please send documentation to laurag@hackbrightacademy.com
Required
If you will be receiving any outside (institutional and/or non-institutional) financial assistance to help with the cost of tuition, you must answer Yes to the following question. (Failure to report outside assistance may result in denial of aid and eligibility and/or repayment of need-based aid that you have previously received.) If you are notified of additional assistance after you have completed this form, please notify laurag@hackbrightacademy.com of the type and amount. *
Secton C - Explanation/Special Circumstances
Use this space to explain any unusual expenses, other debts, or special circumstances that Hackbright should consider when it is deciding how much financial aid, if any, you will receive.
Your answer
Additional space (if needed)
Your answer
Section D - Certification & Authorization
Declaration *
Required
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