Orange Scholarship Fund

Parental Form - to be completed by the parent(s)

Name of parents:

Father

Mother

Name of guardian

Student's Full Name:

Student's Email:

Student's Phone Number:

Parent Email:

Parent Phone Number:

Parent Address:

City:

State:

Zipcode:

Employer City,State Full or Part time

Father Employer

Father City,State

Father Full or Part Time

Mother Employer

Mother City,State

Mother Full or Part Time

Occupation: Father Occupation: Mother

Financial Disclosure - Please attach a copy of pages 1 and 2 (Form 1040) of last year's Federal Income Tax Return. All information will be kept confidential. Form 1040 will be destroyed soon after scholarships are awarded.

Adjusted Gross Income from Federal Income Tax Return

2017 2018 Estimated

Joint Return $ $

Or

Individual Ret (Father) $ $

Individual Ret (Mother) $ $

Briefly describe non-insured medical expenses for the next twelve (12) months.

Own home? Yes No          Mortgage amount on home $

Total savings and investments (include bank, stocks, bonds, trusts) $

Number of children Age of each child

Provide an explanation why this application for your child's scholarship aid should be granted. Include personal circumstances as pertinent to this request for assistance. Attach separate sheet.

Indicate the source's from which you will meet your child's tuition for the first year.

Parental Supplemental page for explanation why

child's scholarship aid should be granted

Signatures: Father Signatures: Mother Date: 12-13-2017