Jim Cox Financial Data Form




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Student/Applicant Name:

Financial Data
The student/applicant IS self-sustaining and
IS NOT claimed by another as an exemption for tax purposes. 		 Yes
The student/applicant IS NOT self-sustaining and IS claimed by another as an exemption for tax purposes.  Yes
As of today, are you married?   Yes
  No
Do you have children that receive support from you?   Yes
  No
Do you have dependents other than your children/spouse who live with you and who receive support from you?   Yes
  No
If you are a dependent, what was your parents/guardians adjusted gross income for 2010?
If you are not a dependent, what was your adjusted gross income for 2010?
Explain your need for scholarship aid. Be specific. Also, state any extenuating circumstances or unusual expenses.
Is there any additional information that you think would be of interest to the selection committee?

Anticipated Expenses for School Year
Tuition
Room and Board
Books and Supplies
Other/Miscellaneous
TOTAL EXPENSES

Anticipated Income for School Year
Employment
Parental/Guardian Support
Savings
Scholarships
Other/Miscellaneous
TOTAL INCOME
       (enter zero if there is no income or expense)

Please note: Scholarship grants must be paid to the institution of higher education at which the student is enrolled.

Acknowledgment:

I attest that the above information is true and accurate to the best of my knowledge.
  I acknowledge
 
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