Taxable Income:



PYTHAGORAS CHILDREN’S ACADEMY TUITION ASSISTANCE 2020-2021 SCHOOL YEAR COVER PAGE Family Name: ____________________________________Dear Applicant,In order to be considered for tuition assistance from Pythagoras Children’s Academy, you must submit the following completed documents by Friday, May 1, 2020. Late and incomplete applications will not be accepted. Cover PageTuition Assistance Application IRS 1040 for 20192020 – 2021 Enrollment Information Grade Level (please enter how many students per grade)T/TH Preschool (9-12)_______Kindergarten_______T/TH Preschool (9-3)_________First Grade_________MWF Preschool (9-12)_________Second Grade________MWF Preschool (9-3)___________Third Grade__________MWF Pre-Kindergarten_________Fourth Grade________Full Time Pre-Kindergarten_______Fifth Grade_________Pythagoras Children’s AcademyTuition Assistance Application 2020 – 2021Section 1: Applicant and Co-Applicant Information: Applicant Information: Parent or GuardianLast Name:__________________ First Name:_____________Social Security Number:_________________________Date of Birth:___________________ Cell Phone:_____________Mailing Address_________________ _________________________City StateZip Codee-mail address:___________________________________Marital Status:Married_______Single______Divorced______Separated_________Widowed__________Employment Status:Full-time_______Part-time_______Stay at home______ Retired_________ Self-employed___________ Unemployed_________Disabled________ Co-Applicant InformationLast Name:_____________________First Name:_____________Social Security Number:_______________________Date of Birth_______________Cell Phone:__________________Mailing Address__________________________________________CityStateZip Codee-mail address:__________________________________________Marital Status:Married_______Single______Divorced______Separated_________Widowed__________Employment Status:Full-time_______Part-time_______Stay at home______ Retired_________ Self-employed___________Unemployed_________Disabled________Section 2:Applicant and Co-Applicant Income Information Size of Household: Number of Adults __Number of children __Do you file a federal income tax return?Yes No __Does the Co-Applicant file a federal tax return? Yes, file jointly with applicant___ Yes,files separately from Applicant____ Does not file Taxable Income:Please list “Adjusted Gross Income” from Applicant’s most recent federal tax return Attach a copy of your 2019 Form 1040 and your 2019 W-2’sIf filing separately, list “Adjusted Gross Income” from co-applicant’s most recent federal tax return. If filing jointly or if no co-applicant, enter “0” Do you own any of the following?Business – Attach Schedule C or C-EZ (Form 1040) and Form 4562 Depreciation and Amortization_____Yes____No Farm – Attach Schedule F (Form 1040) and Form 4562 Depreciation and Amortization_____Yes____No Rental Property – Attach Schedule E (Form 1040) ____Yes____No S Corportation – Attach Schedule E (Form 1040), Form 1065(4 pages), Schedule K-1, Form 8825_____Yes____No Partnership – Attach Schedule E (Form 1040), Form 1065 (4 pages), Schedule K-1, Form 8825____Yes____N0Non-Taxable Income: (Please provide documentation supporting proof of income)Select How income is receivedChild Support received Weekly Monthly Annually$ Social Security benefits receivedthat were not taxed such as SSI Weekly Monthly Annually$ Temporary Assistance forNeedy Families (TANF) Weekly Monthly Annually$ 10. Welfare and/or Aid for Familieswith Dependent Children Weekly Monthly Annually$ 11.Food Stamps Weekly Monthly Annually$ 12.Tuition Support anticipated fromfriends/relatives/employer Weekly Monthly Annually$ 13.Workers’ Compensation Weekly Monthly Annually$ 14. Other nontaxable income Weekly Monthly Annually$ Change of Income:Do you anticipate a decrease in your 2020 household income? If yes, complete the following questions: Yes NoWhat do you anticipate your income to be in the coming year?$ What do you anticipate your spouse’s income to be in the coming year?$ What will cause the reduction in your income in the coming year?Section 3Applicant and Co-Applicant Expense Information:Current Monthly Expenses:Do you rent or own your primary residence? Rent Own OtherMonthly rent or mortgage payment (Include principal, interestTaxes, association fees, and home insurance)$ Do you own a second home (not including rental property)If yes, what is the monthly mortgage payment on your second home (including principal, interest, taxes, association fees, and home insurance) $_________ Yes NoMonthly home equity payments$ Vehicle Information: Complete for each vehicle leased or owned Monthly PaymentMake ModelYearVehicle #1Vehicle #2Vehicle #3Total credit card debt (do not include balances paid in full each month$ Total of all minimum amounts due on monthly credit card statements$ Monthly student loan payments for family members no longer attending college $ Do you have any other loan payments? If yes, please let below:Loan NameMonthly PaymentMonthly child support payments$ Health Insurance Expenses:Is your health insurance paid 100% through your employer?If no, list the health insurance premiums paid per month to the insurance company $____________ Yes NoCurrent Annual Expenses:Annual ExpensesAnnual vehicle insurance$ Total out-of-pocket medical expenses not paid by insurance$ Charitable contributions – cash or checks – per year$ College expensesNumber of family members attending college beginning in the fall of 2020? Total amount of your family’s out-of-pocket cost for college expected this school year? (total tuition less student loan proceeds, scholarships, grants and financial aid) $Elder Care expenses:Number of people for whom you pay elder care expenses? __________Total amount of elder care expenses expected this year?$ Section 4: Applicant and Co-Applicant Assets and Liabilities:Value of cash, savings, and/or checking accounts$ Value of stock, bond investments, mutual funds, and/orcertificates of deposit$ Value of retirement plan assets – 401 (k), 403 (b) and/or IRA’s$ What is your and/or your spouse’s annual contribution to retirementplan assets$__________If you own your home, what is the estimated value?$ If you own your own home, how much do you owe?$ If you own a second home, what is its estimated value$ If you own a second home, how much do you owe?$ Section 5: Authorization and AgreementI (we) agree that the information provided in this form is true, correct, and complete to the best of my (our) knowledge.Applicant SignatureDate_____________________________________Co-Applicant SignatureDate ................
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