Income Verification Form EdChoice Scholarship Program To apply ...

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