Number of family members (include parents’ other children or family members for whom they provide more than half of their support) Ages of all children in the family who were claimed as dependents in the year immediately past Number of family members in college at least half-time during the next calendar year (include the applicant) For the year immediately past, what was the family’s Adjusted Gross Income? (Use Adjusted Gross Income line from federal IRS forms. If information for the year immediately past is not available, give the prior year.) $ Are any special circumstances that have influenced your need for financial assistance? I verify that this information is true and accurate. I understand that failure to provide true and accurate information may result in forfeiture of any scholarship award. Date (month, day, year) Signature of Applicant Date Signature of Parent/Guardian
Number of family members (include parents’ other children or family members for whom they provide more than half of their support) Ages of all children in the family who were claimed as dependents in the year immediately past Number of family members in college at least half-time during the next calendar year (include the applicant) For the year immediately past, what was the family’s Adjusted Gross Income? (Use Adjusted Gross Income line from federal IRS forms. If information for the year immediately past is not available, give the prior year.) $ Are any special circumstances that have influenced your need for financial assistance? I verify that this information is true and accurate. I understand that failure to provide true and accurate information may result in forfeiture of any scholarship award. Date (month, day, year) Signature of Applicant Date Signature of Parent/Guardian
State%204-H%20Foundation%20Scholarship.docx