Application for Tuition Assistance - SAR Academy

SAR ACADEMY
SAR HIGH SCHOOL
655 WEST 254TH ST., RIVERDALE, NY 10471
TEL: (718) 548-1717 ● FAX: (718) 601-0082
APPLICATION FOR TUITION ASSISTANCE
(The information herein will be maintained in strict confidence)
School Year:
For Office use only:
No. C
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TC
PY
OB
The information in this application is given for the purpose of inducing the SAR Academy to grant a scholarship and the
undersigned represents that all statements made herein are true. The undersigned will promptly notify SAR of any
material change in circumstances, and understands that any misrepresentation, failure to supply a material fact, or
failure to advise of any material change in circumstances, may result in denial or forfeiture of tuition assistance. All
questions must be answered; if not applicable mark “N/A.” The committee may request additional information or
verification of any representation made.
INSTRUCTIONS
1. Both parents must sign the application and all items must be answered
2. A full and COMPLETE Form 1040 Federal Tax Form, W2’s, 1099’s, for both husband and wife, as well as NY
State Tax Form for 2009 and 2010 must also be enclosed. In addition, a copy of cancelled check to IRS AND
STATE of payment made to them when you filed your returns.
3. If self-employed, partner or stockholder, furnish complete business returns for the past two years.
A. Family Information
1. Family Name Home Tel.
Address
City, State, Zip
2. Are parents divorced Legally separated
Either of child’s parents deceased
3. Father’s Name Occupation
Birth date
Highest Grade of Education
4. Mother’s Name Occupation
Birth date
Highest Grade of Education
5. Current or Incoming Children at SAR Academy and/ or SAR High School
Name
Grade
Name
Grade
Name
Grade
Name
Grade
Other Children not attending SAR
Name Age School Tuition Paid
Name Age School Tuition Paid
Name Age School Tuition Paid

B. EMPLOYMENT
FATHER
Employer Job Description # of years
Address Annual Pay $
Are you self-employed?
Are you a stockholder in the firm?
If the firm owned in any part by you/ wife’s family?
IRA or Keogh Plan? Annual Contribution $ Current Balance $
Tax Shelter Annuity? Annual Contribution $ Current Balance $
Deferred Income Plan? Annual Contribution $ Current Balance $
403B/ 401K Plan? __________________ Annual Contribution $________________ Current Balance $_______________
MOTHER
Employer Job Description # of years
Address Annual Pay $
Are you self-employed?
Are you a stockholder in the firm?
If the firm owned in any part by you/ husband’s family?
IRA or Keogh Plan? Annual Contribution $ Current Balance $
Tax Shelter Annuity? Annual Contribution $ Current Balance $
Deferred Income Plan? Annual Contribution $ Current Balance $
403B/ 401K Plan? __________________ Annual Contribution $________________ Current Balance $_______________
C. FINANCIAL
1. Do you (mother/ father) own a home? Co-op Summer/ Winter Home or Apt.
Purchase Price $
Date of Purchase
Original Mortgage $ Present Balance $
Monthly Mortgage Payment $ Monthly Real Estate Taxes $
Annual Home Insurance $ Monthly Maintenance $
Do you rent? Monthly rental? No. of years at present address
2. Line 37 (adj. gross income) of latest 1040 Federal Tax Return $ Line 37 of Wife’s 1040 Form $
3. Other/ Outside Income
FATHER
MOTHER
Self Employment $ $
Fees/ Commissions $ $
Dividends $ $
Interest $ $
Rentals $ $
Child Support $ $
Other $ $
4. Banking– Name and Addresses of Banks at which family maintains accounts
Savings Account
Name Address Acct # Present Balance $
Name Address Acct # Present Balance $
Checking Account:
Name Address Acct # Present Balance $
Name Address Acct # Present Balance $
Money Market Account
Name Address Acct # Present Balance $

5. Do any of your children have Trust, Guardianship, or Gift to Minor Accounts? Amt. $
6. Has your family received financial assistance from other sources, such as relatives, grandparents, etc. Amt. $
7. Do you complete your own tax returns? Yes No
If no, give name address, phone number of person who does
8. List all other assets (Stock, Bonds, US Bonds, Properties and Values, CD’s etc.)
Amt. $
Amt. $
Amt. $
Amt. $
D. Family’s Monthly Obligations/ Payments: (approximate)
Car/ Loans $ American Express $ Visa $
Medical $ Master Charge $ Gas Cards $
Bank Loans $ Store Charge: Name Amount $
Domestic Help $ Name Amount $
Other
E. Other
1. Does the family own a car Does the family lease a car Total # of cars in family
Year Make and Model ; Year Make and Model
Year Make and Model ; Year Make and Model
2. Camp
Child Camp Fee $ Length of Stay
Child Camp Fee $ Length of Stay
Child Camp Fee $ Length of Stay
Child Camp Fee $ Length of Stay
3. Vacations
List Parent or family vacations taken in the past two years
Last year– Where
Previous year– Where
F. Assistance Requested
Amount we can pay for the school year $
I/We understand that all scholarships offered by SAR are moral scholarships and I/We recognize that if we are
granted a scholarship by SAR then we will have a future moral obligation to support the SAR Scholarship Fund to
the best of our ability. If financial circumstances allow, we will repay the amount of any scholarship received.
I (we) affirm that the above information is accurate and complete and agree to advise the school promptly of any
changes in the above information.
SIGNATURES:
Father
Mother
DATE:

NO APPLICATION WILL BE PROCESSED WITHOUT THE ABOVE REQUIRED INFORMATION.
ALL QUESTIONS MUST BE ANSWERED.– IF NOT APPLICABLE, MARK “N/A”
MAIL TO:
SAR ACADEMY
655 West 254th Street
Riverdale, NY 10471
Attention: Tuition– Scholarship Committee
Call 718-548-1717, Ext. 1200 with any inquiries
Remarks:
PLEASE DO NOT WRITE BELOW THIS LINE
DATE
COMMITTEE
MEMBERS
NO. OF
CHILDREN
ACTUAL
TUITION
SCHOLARSHIP
GRANT
TUITION DUE
REMARKS