STO_Eligibility_Application-2018.xlsx
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NICSTO ELIGIBILITY APPLICATION
2018-2019
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(Northwest Iowa Christian Schools Tuition Organization)
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First Name
Annual Income *
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Last Name
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Spouse
Annual Income *
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Address
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*
Annual total income from your most recent tax forms.
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City, State if you use Form 1040 line 22
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if you use Form 1040A line 15
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Zip
if you use Form 1040EZ line 4
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*
A copy of page 1 of the previous year's tax
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form must accompany this application.
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List Children Living in Household
AgeSchool
Grade
Annual Income
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1.
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2.
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3.
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4.
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5.
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6.
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TOTAL FAMILY INCOME
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Eligibility Guidelines are printed on the back side of the application.
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Please explain the circumstances that may be helpful for the committee.
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Certification and Signature:
I certify (promise) that all information on this application is true and
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that all income is reported. I understand that I will be receiving tuition assistance based on the information
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provided. I understand that NICSTO or school may verify or check the information provided. I understand
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that if I purposely give false information I will not receive tuition aid and will not be eligible to reapply.
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Signature of Adult Completing Form
Printed Name of Adult Completing Form
Date
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Phone Number
Social Security Number (Required)
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For Administrative Use:
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Application Approved: Date:
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Application Denied: Reason Denied:
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Use this GraphNo. InFederal PovertyNICSTO GUIDELINES
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to determine yourFamilyIncome GuidelinesHousehold Income
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Eligibility1$12,140$36,420
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2$16,460$49,380
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3$20,780$62,340
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4$25,100$75,300
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5$29,420$88,260
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6$33,740$101,220
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7$38,060$114,180
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8$42,380$127,140
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For each additionalmember$4,320$12,960
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Federal Register Poverty Guidelines Jan 31, 2018
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