PRESCHOOL FINANCIAL ASSISTANCE APPLICATION
Miss Mollie's School of Grace - Grace Lutheran Church, Durham, NC
School Year: *
Today's Date: *
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Student Information:
Note: Financial Assistance Only Given for Tuition
Last Name of Student: *
First Name of Student: *
Age of Student: *
Parent/Guardian Information #1
Relationship to Student (Check One) *
Required
Name of Parent/Guardian: *
Address: Street, City, State & Zip Code *
Home Phone
Cell Phone
Work Phone
Parent/Guardian Information #2
Relationship to Student (Check One) *
Required
Name: *
Address: Street, City, State & Zip Code *
Home Phone:
Cell Phone:
Currently Employed (Check one):
Work Phone:
Other Dependents:
Dependent #1: List Name, Age, Work or School, Tuition/Child Care $:
Dependent #2: List Name, Age, Work or School, Tuition/Child Care $:
Dependent #3: List Name, Age, Work or School, Tuition/Child Care $:
Dependent #4: List Name, Age, Work or School, Tuition/Child Care $:
FAMILY INCOME/ASSETS:
Please provide copies of 2 most recent pay stubs, if employed.
Monthly Income:
This Year's Income:
Last Year's Income:
FAMILY INCOME/ASSETS for PARENT/GUARDIAN #1: (per month)
Please provide copies of 2 most recent pay stubs, if employed.
Worker's Compensation:
Social Security:
Aid to Families with Dependent Children:
Food Stamps:
Other Tuition Assistance:
FAMILY INCOME/ASSETS for PARENT/GUARDIAN #2: (Per Month)
Please provide copies of 2 most recent pay stubs, if employed.
Worker's Compensation:
Social Security:
Child Support:
Aid to Families with Dependent Children:
Food Stamps:
Other Tuition Assistance:
FAMILY EXPENSES (per month)
Utilities:
Rent/Mortgage:
Health Expenses:
Vehicle Payment for Vehicle #1
Vehicle Payment for Vehicle #2
Child Support (paid by you):
Other Expenses: Insurance, Credit Cards, Student Loans, etc.
SPECIAL CIRCUMSTANCES:
LIST REASON(S) YOU ARE REQUESTING FINANCIAL ASSISTANCE:
SIGNATURE REQUIRED
I CERTIFY THAT THE INFORMATION ON THIS FORM IS, TO THE BEST OF MY KNOWLEDGE, COMPLETE AND ACCURATE.
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