Income Verification Form EdChoice Scholarship Program To apply ...

EdChoice Scholarship ProgramIncome Verification FormPrint FormTo apply for low income status, please complete the following:1. Complete and sign this form2. Attach documentation of all sources of income. Documents should be representative of currentincome. Acceptable CURRENT documentation may include:One month of pay stubsChild support history print outCurrent W-2's with tax return1099's or business recordsProof of eligibility for OWF/food stampsBenefit statement Social SecurityBenefit statement from unemploymentcompensationAn official document showing current income3. Mail this form and COPIES of all required documentation to:Ohio Department of EducationEdChoice Scholarship Program25 S. Front Street, Mail Stop 309Columbus, Ohio 43215Keep a copy of this completed form for your recordsThis form and all supporting documents must be received at ODE by April 15, 2011ODE.SOF.EC.IncomeVerification.12.01.10Page 1

EdChoice Scholarship ProgramIncome Verification FormPrimary Parent/GuardianSecondary Parent/GuardianFirst Name Middle LastRelationship to Scholarship Applicant:First Name Middle LastRelationship to Scholarship Applicant:MotherStep ParentMotherStep ParentFatherLegal GuardianFatherLegal GuardianMarital StatusMarital StatusMarriedNever MarriedSeparated Divorced WidowedMarriedNever MarriedSeparated Divorced WidowedResidencyResidencyStreet Address Apt #Street Address Apt #OHIOOHIOCityZIPCityZIPHome PhoneCell PhoneHome PhoneCell PhoneE-MailE-MailODE.SOF.EC.IncomeVerification.12.01.10Page 2

HouseholdEdChoice Scholarship ProgramIncome Verification FormAdultsHow many adults live in your house?Starting with yourself, list all of the adults who live in your household.Name (first and last) Gender Date of BirthLast FourDigits SSN#Relationship to YouReceives IncomeM / F Self YES NOM / F YES NOM / F YES NOM / F YES NOM / F YES NOM / FYESNOChildrenHow many children live in your house?List all of the children who live in your household, including those who are not applying for a scholarship.Name (first and last) Gender Date of BirthM / FM / FM / FM / FM / FM / FLast Four DigitsSSN#Relationship to You New Renew NAIf you require more space, please duplicate this page and submit with application.ODE.SOF.EC.IncomeVerification.12.01.10Page 3

IncomeEdChoice Scholarship ProgramIncome Verification Form* Income is any money or financial resources that you and the people in your household receive from employment, child/spousal support, food stamps, disability benefits,unemployment compensation, workers compensation , social security, SSI, OWF, veterans benefits and any other sources of income.* Documents will need to be provided for each type of income.* In the table below, list each person that has earned or unearned income. If someone has more than one source of income, use multiple lines.Name (first and last) Employer or Income source Gross Amount (before taxes) How Often ReceivedEXAMPLE : John Smith Child Support $275.00 monthlyDoes anyone in your household PAY child support? Please Circle One YES / NONAME: Amount: How Often:I declare that the information on this form is true, correct and complete to the best of my knowledge. I agree to provide documents to verify theinformation listed. I authorize the Ohio Department of Education to make whatever contacts are necessary to verify the information I haveprovided.Parent/Guardian SignatureIf you require more space, please duplicate this page and submit with application.DateODE.SOF.EC.IncomeVerification.12.01.10Please Return to:Ohio Department of EducationEdChoice Scholarship Program25 S. Front Street, Mail Stop 309Columbus, Ohio 43215MUST be received byApril 15, 2011, 4:00 p.m.Page 4