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PSA Scholarship Application
Please complete this form if you believe you will qualify for a PSA Scholarship
First Name *
Last Name *
Parent's Name(s) *
Phone Number *
What is your current Adjusted Gross Income? (AGI as reported on your most current tax return, 2016) *
Number of family members currently living in your home (As reported on your 2016 Federal Tax Return) *
Does you child currently qualify for free or reduced lunch? *
Which level do you qualify for based on your federal income tax Adjusted Gross Income? (Free lunch qualifies for Level 1, Reduced lunch qualifies for Level 2)
By clicking this box and submitting this application, I understand that I will be required to provide proof of eligibility of scholarship to PSA. I also understand that this means submitting either a copy of my 2016 tax return showing the AGI and household size, or confirmation of eligibility for free or reduced lunch. *
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