2017-2018 Financial Worksheet
PCC Foundation Scholarship Application
Due at time of scholarship deadline (March 1st, 2017 11:59pm)
Directions: Complete the following blanks and save to your computer. Then log into your PCC Foundation
Scholarship Application and upload the form. If you cannot fill out the form, please go to the Computer
Resource Center for assistance. www.pcc.edu/crc. If you have questions please email [email protected].
The following information is used by the PCC Foundation Office in order to determine a student’s economic need. It is required that
either a student complete a FAFSA application, or this worksheet, in order to have a complete scholarship application. This information
will be kept confidential and will not be used for any reason other than to support the scholarship application.
A. Student’s Information
Last name, First name MI
PCC Email Address
PCC ID (G#)
Primary phone number
Date of Birth
B. Family Information (If you were born before January 1, 1994, skip section B)
(Please indicate all monetary values in dollars)
1.
List your parents (step-parents, legal guardians, adoptive parents), and others that your parents financially support.
(siblings, dependents, etc.) If you do not have contact with your parents, or would like to further explain any extenuating
family circumstances, please attach an additional sheet with your name and statement.
Family member’s name
Ann Snieder (example)
Relation to student
Mother
Age
65
In College?
yes
(if you need more room, continue on an additional page)
2.
Indicate your parent’s 2016 income. (If they did not have an income in 2016, indicate zero)
Family member’s name
Joe Ruez (example)
Employer
Petco
2016 Earned Income
$36,000
C. Student’s Income Information
(Please indicate all monetary values in dollars)
1.
2.
If you were employed during 2016, list the employer’s name and how much you earned through the year. If you did not
work, indicate N/A in the chart. Please include your spouse’s income here as well if you are married.
Employer’s Name
2016 Amount Earned
Suzy’s Auto Body Shop (example)
$2,000.00
Did you receive financial help from friends or family outside of the United States in 2016?(circle one)
Yes ☐
No ☐
a.
3.
Did you receive financial support from a sponsor or family member in the United States in 2016?
Yes ☐
No ☐
a.
4.
If so how much did you receive?
Did you receive any other financial support for 2016?
Yes ☐
No ☐
a.
5.
If so how much did you receive?
If so list it here
If you have a personal checking/savings account, please indicate the current balance.
a.
Current balance of checking/savings accounts
D. Student’s Financial Obligations
1.
Indicate below if you financially support anyone other than yourself here in the United States. (children, parents,
dependents, etc.)
Full Name
Age
Relation to student
(example) Joey Hannel
12
Son
2.
Did you pay child support in 2016?
Yes ☐
No ☐
If yes, indicate how much you paid in 2016.
3.
Did you provide monetary support to anyone outside of the United States in 2016?
Yes ☐
No ☐
If yes, indicate how much you provided in 2016.
If there are any other circumstances related to your finances that you would like to explain, please indicate those here:
E.
Certification and Signature
If you need assistance with the form:
I certify that all of the information reported on this
worksheet is complete and correct. The student must
sign this worksheet
PCC Foundation Office
[email protected], 971-722-4385
Sylvania, CC 234
Student’s Signature
Date