| Note: Applicant’s income will be verified with tax return, paycheck stub, or other appropriate document. | 
		
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| Note: to Parent/Guardian: Please circle the size of your household and your total household income below, and | 
		
| sign to verify your income. Household income must be equal to or less than the amounts listed for each pay period | 
		
| for your child to be eligible for the scholarship. You will need to present documentation verifying your income. | 
		
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			Tier 1 (Fees Covered) | 
			Tier 2 (Fees Covered) | 
			Tier 3 (Fees Covered) | 
		
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			Scholarship 75% / 25% Participant | 
			Scholarship 55% / 45% Participant | 
			Scholarship 35% / 65% Participant | 
		
| Household Size | 
			Annual Income | 
			Annual Income | 
			Annual Income | 
		
| 1 | 
			$16,744 | 
			$23,828 | 
			$30,912 | 
		
| 2 | 
			$22,646 | 
			$32,227 | 
			$41,808 | 
		
| 3 | 
			$28,548 | 
			$40,626 | 
			$52,704 | 
		
| 4 | 
			$34,450 | 
			$49,025 | 
			$63,600 | 
		
| 5 | 
			$40,352 | 
			$57,424 | 
			$74,496 | 
		
| 6 | 
			$46,254 | 
			$65,823 | 
			$85,392 | 
		
| 7 | 
			$52,156 | 
			$74,222 | 
			$96,288 | 
		
| 8 | 
			$58,058 | 
			$82,621 | 
			$107,184 | 
		
| each additional | 
			$5,902 | 
			$8,399 | 
			$10,896 | 
		
| family member add: | 
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| add | 
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| Income is defined as any monies earned before any deductions such as income taxes, social security taxes, insurance premiums;  | 
		
| charitable contributions, and bonds. It includes the following: (1) Monetary compensation for services, including wages, salary,  | 
		
| commissions or fees; (2) net income from non-farm self employment; (3) social security; (4) dividends or interest on  | 
		
| savings or bonds or income from estates or trusts; (5) net rental income; (6) public assistance or welfare payments; | 
		
|  (7) unemployment compensation; (8) government civilian employment or military annuities; (9) private pensions or annuities;  | 
		
| (10) alimony or child support payments; (11) regular contributions from persons not living in the household; (12) net royalties ; | 
		
|  and (13) other cash income. Other cash income would include cash amounts received or withdrawn from any source including | 
		
|  savings, investments, trust accounts, and other resources that would be available. | 
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