LA
louisiana
A School Tuition Organization
Serving Louisiana Families
TUITION DONATION REBATE PROGRAM STUDENT APPLICATION
2015-16 SCHOOL YEAR
Thank you for your interest in ACE Scholarships Louisiana and in the Louisiana Tuition Donation Rebate Program (TDR). The TDR
Program allows qualified Louisiana children to receive scholarships to qualified K-12 private schools, allowing parents to choose a
school that will best prepare their children for college, for careers, and for life.
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY:
ACE Scholarships Louisiana is a School Tuition Organization and offers scholarships to qualified children on a first-come, firstserved basis for as long as funds are available. Children are listed by ACE in the order in which complete applications are received
and after all information has been verified. Completion of this application does not guarantee funding from ACE.
To receive funding from ACE, students must attend an ACE Partner Private School. To receive the list of ACE Partner Private
Schools please email [email protected] or call (504) 491-1813.
To get in line for possible ACE funding, please complete the application to the best of your ability, sign the last page and return all
pages to [email protected] or by fax to (720) 266-6798 as soon as possible.
For more information visit www.acescholarshipsla.org.
SCHOLARSHIP AWARD AMOUNTS AND DEADLINES
SCHOLARSHIP AWARD AMOUNTS: Scholarship amounts may vary slightly depending on the private school you
choose, but in general the scholarship amounts are as follows:
•For grades K-8 the scholarship is $4,147.66 per school year
•For grades 9-12 the scholarship is $4,666.12 per school year
(Scholarship cannot exceed total school tuition and required fees)
DEADLINES: For the 2015-16 SY, ACE will begin collecting applications on January 1, 2015. There is no
deadline but as the scholarship is first come, please submit as soon as you have all required items.
SECTION 1 – SCHOOL TUITION ORGANIZATION INFORMATION
SCHOOL TUITION ORGANIZATION CONTACT INFORMATION
Name
Web Address
ACE Scholarships Louisiana
www.acescholarshipsla.org
Street Address
1201 East Colfax Avenue, Suite 302
City
Denver
Phone
(504)491-1813
State
Zip Code
Colorado
80218
Fax
Email
(720)266-6798
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[email protected]
LA
A School Tuition Organization
Serving Louisiana Families
louisiana
SECTION 2 – STUDENT INFORMATION
STEP 1: ELIGIBILITY CHECK
INSTRUCTIONS: Please answer each of the following questions. You must answer “YES” to all questions to
qualify for a Tuition Donation Rebate Scholarship
YES
NO
My child is a resident of Louisiana.
YES
NO
My child attended a Louisiana public school during the 2014-2015 school year.
OR - My child is attending kindergarten for the first time in the 2015-16 school year.
YES
NO
My family income is less than the amount listed below.
Students enrolled in a private school during the 2014-15 school year, as a part of the Louisiana Scholarship Program, are
eligible to apply for a scholarship for the 2015-16 school year under the Rebate Program and are given priority before new
applicants. However, students are not able to receive funding from both programs for the same school year.
SCHOLARSHIP ELIGIBILITY - 250% of Current Federal Poverty Guidelines
FAMILY
HOUSEHOLD SIZE
YEARLY
AMOUNT ($)
MONTHLY
AMOUNT ($)
BI-WEEKLY
AMOUNT ($)
WEEKLY
AMOUNT ($)
2
39,325
3,277
1,521
756
3
49,475
4,123
1,902
951
4
59,625
4,969
2,294
1,147
5
69,775
5,815
2,684
1,342
6
79,925
6,660
3,074
1,537
7
90,075
7,506
3,464
1,732
8
100,225
8,352
3,854
1,927
Add the following
amount for each
additional family member.
10,150
846
391
195
STEP 2: STUDENT INFORMATION
INSTRUCTIONS: Please fill out to the best of your ability.
1. Last Name, First Name and Middle Initial
2. Suffix (Jr., Sr., etc.)
3. Date of Birth (MM/DD/YYYY)
4. Student Social Security Number
5. Gender (choose one)
(required by
state law)
MALE
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FEMALE
LA
A School Tuition Organization
Serving Louisiana Families
louisiana
6. Ethnicity (for reporting only)
Hispanic
7. Race (choose all that apply)
American
Indian
Not Hispanic
Pacific
Islander
White
Asian
Black
8. Street Address (include apartment number
if applicable)
9. City, State and Zip Code
10. What private partner school is your student
currently attending?
11. Which grade is your child currently in for the
2014-15 school year? (K-12)
Raising my child with spouse/partner
12. Please choose the option that best describes
your family situation. (choose one)
A single parent raising my child by myself
Divorced and I share custody with the other parent
Other - please specify: ____________________________________________________________
13. Did your student receive a scholarship
through the Louisiana Scholarship Program
in the 2014-15 school year?
Yes
No
STEP 3: PARENT/LEGAL GUARDIAN INFORMATION
INSTRUCTIONS: Please fill out to the best of your ability.
1. Parent/Legal Guardian Last Name
2. Parent/Legal Guardian First Name
and Middle Initial
3. Suffix (Jr., Sr., etc.)
4. Relationship to Student (choose one)
Father
Mother
Grandfather
Step-Mother
Step-Father
Grandmother
Aunt/Uncle
Guardian/Other
5. Mailing Address
6. City, State, Zip Code
7. Home Phone and Cell Phone
8. Email Address
9. Family Household Income
10. Number in Family Household
11. Highest level of education of Parent/Legal
Guardian (choose one)
Some High School
High School Graduate
Certificate Program
Some College
Bachelor’s Degree
Graduate Degree
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Associate’s Degree
LA
A School Tuition Organization
Serving Louisiana Families
louisiana
STEP 4: STUDENTS WITH DISABILITIES
INSTRUCTIONS: Please fill out to the best of your ability.
Does your child have an Individual Education Plan (IEP)?
choose one:
YES
NO
If yes, please check your child’s primary exceptionality. If no, please go to Step 5.
o Autism
o Visual Impairment – Blindness
o Hearing Impairment – Deafness
o Deaf – Blindness
o Emotional Disturbance
o Developmental Delay
o Multiple Disabilities
o Specific Learning Disability
o Orthopedic Impairment
o Intellectual Disability – Mild
o Intellectual Disability – Moderate
o Intellectual Disability – Severe
o Other Health Impairment
o Severe Learning Disability
o Traumatic Brain Injury
o Intellectual Disability – Profound
o Speech or Language Impairments
o Speech or Language Impairment
– Fluency
o Speech or Language Impairment
– Language
o Speech or Language Impairment
– Voice
STEP 5: INCOME VERIFICATION
INSTRUCTIONS: Complete Part A or B (you do not need to complete both)
A. If you participate in any of the programs below, please check the circle next to the program. When you submit your
application, please include evidence that you participate in the program.
o
Louisiana Purchase Card
o SNAP
Benefits
o
Social Security Benefits
B. If you do not participate in any of these programs, please submit proof of income for every member of your household.
This can consist of any of the following:
• Federal Tax Return
• W-2s from all employers for the period ended December 31, 2014
• Unemployment compensation statement for the period ended December 31, 2014
• Alimony as shown in court decree or agreement
• Social Security benefits statement for the period ended December 31, 2014
• Pension statements for the period ended December 31, 2014
STEP 6: RESIDENCY VERIFICATION
INSTRUCTIONS: Please include proof of residency when you submit your application.
The address of residency should be where the child lives and should match the student address listed in Step 2. The proof
can be dated for anytime after January 2015. This proof can consist of any of the following:
• Rental lease agreement/mortgage agreement
• Electricity/Gas bill
• Telephone bill
• Cabel or Internet service bill
• Sewerage/Water bill
• Current official letter from a Government Afency (DSS, DHH)
• Homestead Exemption Notice
• Property Tax Notice
If you are unsure of what documentation you can use to prove your income, residency, or have any questions, please feel
free to call the Louisiana Department of Education at 1.877.453.2721.
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LA
A School Tuition Organization
Serving Louisiana Families
louisiana
STEP 7: SIGNATURE
Parent/Legal Guardian’s Printed Name
Parent/Legal Guardian’s Signature
Date
OPTIONAL SECTION
STEP 1: Please tell us which ACE Partner Private School(s) you plan on applying to for your child (you may provide up to three
schools with your first choice listed first, etc.).
CHOICE #1
CHOICE #2
CHOICE #3
SCHOOL
NAME
CITY
PHONE
STEP 2: If your child receives funding from ACE Scholarships Louisiana, we ask that parents agree to the following ACE policies.
Please check the boxes to the left of each policy if you agree to these terms. ACE funding will not be withheld if you choose not to
check one or both of the boxes.
Please check the box if you agree to the following policy:
I agree to have my child’s school release to ACE Louisiana the results of the required state assessments in Math and Language Arts
under the TDR, as well as his/her attendance records. I understand that this information will be used by ACE Scholarships Louisiana
to demonstrate the impact of the TDR program and that such information will not be made public in any way that individually
identifies the results as being related to my child. I further understand that the results of my child’s assessments and attendance
will in no way affect my child’s eligibility for a scholarship from ACE Scholarships Louisiana in the TDR Program.
Please check the box if you agree to the following policy:
I agree to give ACE Scholarships Louisiana permission to use the quotations, video and audio footage, and/or photographs that I
(or my child) either provide directly to ACE or allow ACE staff or their contractors to capture at ACE sanctioned events, photos
sessions or other meetings and gatherings. I understand that these photographs and quotations could be used in publications,
print advertisements, direct-mail pieces, electronic media (like video, CD, internet), or other promotion materials. I release ACE
Scholarships and its designees from liability for any violation of any personal or proprietary rights I may have in connection with
using these quotations or photos.
STEP 3: CHECK LIST
Before you submit your application, please check that you have done the following:
Completed all boxes in Sections 2 and 3
Attached Income Verification documents as described in Step 5
Attached Proof of Residency as described in Step 6
Signed the application in Step 7
If you have completed all the steps above, your application will be placed in line for funding from ACE. Your application will not be
considered complete until all of the steps above are taken.
Thank you!
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