Griswold Family Association



GRISWOLD FAMILY ASSOCIATION Scholarship Application page 3

Part Il - Financial data to be completed by parent or guardian.

Please take the information from your completed 2018 IRS income tax return (1040, 1040A, or 1040EX)

A. Adjusted gross income $ ___________

B. Total US tax paid ___________

C. Income earned from work by:

Father ___________

Mother ___________

D. Non-taxable income: Social Security, Child support, Welfare, Tax-exempt interest, Veteran's benefits, etc. ___________

E. Medical/Dental expenses not paid by insurance ___________

F. Total number of exemptions ___________

G. Total savings and investments at December 31, 2015 (cash, savings and checking accounts, stocks, bonds, mutual funds, CD's, etc.)


H. Applicant's parents' marital status is _____ married_______ single____ separated_____ divorced_______ widowed_______

I. Total of family members who will be attending post-secondary school at least half-time during 2019-2020 school year (include applicant)


Part III - Certification and Signatures Certification: All of the information on this form is true and complete to the best of my (our) know- ledge. If asked by an authorized official, I (we) agree to provide proof of the information I (we) have given on this form. I (we) realize that this proof may include a certified copy of my (our) U. S. Income Tax Return. I (we) also realize that if I (we) do not provide such proof if asked, the applicant may not receive scholarship aid.

Signatures: Applicant ______________________________Parent/Guardian _______________________________ Date ___________________