St. Bernard Day School Financial Assistance Application: 2002-2003
The Financial Assistance Application MUST BE returned to the St. Bernard School Business Office, 2020 Hillside Lane, Green Bay, WI, 54302 by June 1, 2002. Families will receive notification of the amount of their financial assistance in August. In order to process the Financial Assistance Application, a 2001 1040 TAX FORM must accompany it.
Date:_______________________________
1. Family Information
Student Social Security Number ________________________________________________________
Student Name______________________________________________________________________
Address___________________________________________________________________________
City, State, Zip______________________________________________________________________
Telephone Number___________________________________________________________________________
Father's/Stepfather's Name_________________________ Father's/Stepfather's
Age________
Mother's/Stepmother's Name _______________________ Mother's/Stepmother's
Age_______
Parents' Marital Status: ____Married ____Single ____Divorced ____Widowed ____Separated
If marked separated or divorced, who will be responsible for paying tuition?
_________________________________
Grade in School Next Year (2002-03)
Parish/Church Affiliation ______________________________________________________________
2. List All Dependents (including prospective students)
Name School Tuition
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
| 3. Income, Earnings and Benefits | Actual 2001 | Estimated 2002 |
| 2001 Adjusted Gross Income | $_________ | $_________ |
| (IRS form 1040, 1040a OR 1040EZ) | $_________ | $_________ |
| 2001 US Income Tax Paid | $_________ | $_________ |
| Father/Stepfather 2001 Income from work | $_________ | $_________ |
| Mother/Stepmother 2001 Income from work | $_________ | $_________ |
| Child Support | $_________ | $_________ |
| Untaxed Income and Benefits | $_________ | $_________ |
| (Include Social Security Benefits, AFDC or ADC, Deductable IRA/Keough Payments, Tax exempt interest, Earned income credit, Workers' Compensation, and any other untaxed income.) | ||
4. Asset Information
| A. Parent | Current | ||
| Cash, savings and checking | $ _________ | ||
| Home: |
Value | $ _________ | |
| Debt | $ _________ | ||
| Other realestate/investment | Value | $ _________ | |
| Debt | $ _________ | ||
| Business/Farm | Value | $ _________ | |
| Debt | $ _________ | ||
| Investments (stocks/bonds, etc.) | Value | $ _________ | |
| Value Retirement Contributions | Value | $ _________ | |
| Annual Contribution | Value | $ _________ | |
| Total Value | $ _________ | ||
| B. Student | |||
| Cash, savings and checking (Includes trusts, stocks, bonds, etc.) |
$ _________ | ||
IF THERE ARE ANY SPECIAL CIRCUMSTANCES THAT YOU FEEL THE SCHOOL SHOULD
BE MADE AWARE OF, SUBMIT THAT INFORMATION ON A SEPARATE PIECE OF PAPER AND
RETURN IT WITH THIS APPLICATION.
If you have any questions about the completion of this form, please contact
the St. Bernard School Office at 920-468-5026
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