Fillable 2015-16 TUITION ASSISTANCE GRANT PROGRAM APPLICATION (Averett College)

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2015-16 TUITION ASSISTANCE GRANT PROGRAM APPLICATION (Averett College)

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This document contains important information for all students participating in the Virginia Tuition Assistance Grant (VTAG) program administered by the
institutions and the State Council of Higher Education for Virginia (SCHEV). It also provides details on the eligibility requirements, application deadlines,
and criteria for award distributions. Please read this document carefully.
BACKGROUND INFORMATION
VTAG is a non need-based grant for Virginia residents attending a participating Virginia private college or university. Funds for this grant have been
appropriated by the state legislature since 1973. While the maximum award is authorized each biennium, the amount is not guaranteed and can vary
annually. The exact amount of each academic year’s award is determined by the available funding and the total number of eligible applicants. If funding
is insucient to fully award all students, it is possible that the spring award will be adjusted and some students will receive no award. The college nancial
aid oce will have the most current information about the expected maximum award. See below for the categories and prioritization of awards.
ELIGIBILITY REQUIREMENTS
Students must meet all the eligibility requirements set forth by the General Assembly, Section 23-7.4 and Section 23-38.11-17 of the Code of Virginia and
in the VTAG regulations, 8 VAC 40-71. All requirements are not specied in this application. The basic eligibility requirements are:
•DomiciledresidentofVirginiaforatleastoneyearpriortoreceivingVTAGordependentofcertainmilitarypersonnel.
[A student who is in Virginia primarily to attend college is not considered to be a domiciled resident.]
•Enrolledasafull-timestudentataneligibleinstitutioninaneligibledegreeprogram.
[For specics on “full-time” or “eligible degree program,” please contact your institution’s nancial aid oce.]
•AcompletedVTAGapplicationsubmittedtoyourinstitution’snancialaidoce.
APPLICATION DEADLINES AND AWARD DISTRIBUTION CRITERIA
Conditions for reduction of the award amount and eligibility are described in program regulations. If funds are not sucient to make full VTAG awards to
all eligible students, a priority system is used to determine the size of the awards. Students in the rst categories must receive full funding before subse-
quent categories can be considered; however, categories 1 and 2 are combined and will receive the same award amount.
Priority System:
•Category 1: Returning students who received a VTAG award in the previous scal year. This category includes transfer students who received a
VTAG award in the previous scal year at another institution.
•Category 2: New and re-admit students who are eligible for fall or fall and spring term awards and who apply for the VTAG program by July
31, 2015. This category also includes returning and transfer students determined to be eligible in the previous scal year, but not awarded.
•Category 3: New and re-admit students who are eligible for fall or fall and spring term awards and who apply for the VTAG program between
and including August 1 and September 14, 2015.
•Category 4: All students eligible for spring term awards only (except those who received the award in the previous scal year), and who apply
by December 1, 2015.
After the March verication of actual spring term enrollments, SCHEV will determine the nal award amounts for category 1 and 2 applicants.
If necessary, the spring amount will be adjusted. Awards, if any, for category 3 and 4 applicants cannot be determined until mid-spring.
ADDITIONAL INFORMATION
Total support cannot exceed two years for an associate program, no more than four years for undergraduate programs, and no more than three years for
all post-undergraduate programs except for medicine and pharmacy, which allow a maximum of four years. Recipients of the awards have the responsi-
bility to notify, in writing, the institutions they attend of any name or permanent address changes.
The institutions and SCHEV do not discriminate on the basis of race, color, national origin, sex, religion, age, or disability when making award decisions
or reviewing appeals; any information requested for these items is for statistical purposes only.
Public Law 93-579, referred to as the Federal Privacy Act, requires that any federal, state, or local agency that requests an individual to disclose his Social
Security number inform the individual by which statutory or other authority the number is solicited, whether that disclosure is mandatory or voluntary,
and what uses could be made of it. SCHEV, as required by published regulations, requests each applicant for its student aid programs to submit a Social
Security number on a voluntary basis. The Council uses a student’s Social Security number for unique identication purposes in the application and
reporting processes.
*** If you have further questions regarding VTAG, please contact your institution’s nancial aid oce. ***
2015-16 TUITION ASSISTANCE GRANT PROGRAM APPLICATION
— IMPORTANT INFORMATION FOR STUDENTS AND PARENTS —
Student’s Name (please print)
State Council of Higher Education for Virginia 1 of 4 Update 06/14
Appalachian College of Pharmacy
Averett University
Blueeld College
Bridgewater College
Christendom College
Eastern Mennonite University
Edward Via Virginia College of
Osteopathic Medicine
Emory & Henry College
Ferrum College
George Washington University
(VA campus only)
Hampden-Sydney College
Hampton University
Hollins University
Jeerson College of Health Sciences
Liberty University
Lynchburg College
Mary Baldwin College
Marymount University
COLLEGES AND UNIVERSITIES APPROVED FOR PARTICIPATION
Randolph College
Randolph-Macon College
Regent University
Roanoke College
Shenandoah University
Southern Virginia University
Sweet Briar College
University of Richmond
Virginia Union University
Virginia Tech Carilion School
of Medicine
Virginia Wesleyan College
Washington & Lee University
Graduate Students: As of July 1, 2009, only students enrolled in graduate programs in the health professions -- as certied by a 51 series CIP code -- are eligible to receive VTAG.
CollegeIssuedStudentIDNumber
SECTION A: Student Information
Please type or print in ink. Be sure to read all directions carefully. THE PROCESSING OF YOUR APPLICATION WILL BE DELAYED UNLESS ALL
PAGES ARE COMPLETED, AND THE APPLICATION IS SIGNED AND DATED.
1. Name: ______________________________________ __________________________________________ ___________________
Last First Middle Initial
2. Social Security Number: XXX -XX - ____ ____ 3. DateofBirth:_____/_____/_______
4. Sex: M F 5 A. Phone: (______) _________- ____________ 5 B. Email: ________________________________________
6. Permanent address: ___________________________________________________________________________________________
Street City State ZIP code
7. Where have you lived in the last two years? List current address rst. Dates must be included.
From (MM/DD/YY) To (MM/DD/YY) Street City State ZIP code
a.____/____/____ to today ________________________________ __________________ ___ ______________
b.____/____/____ to____/____/____ ________________________________ __________________ ___ ______________
c.____/____/____ to____/____/____ ________________________________ __________________ ___ ______________
8. Are you a United States Citizen or Permanent Resident? Yes No
If “No,” attach a copy of your INS documentation to this application, indicating your classication and expiration date.
9. If you are male, have you complied with the U.S. Selective Service registration requirement?
Yes
Female
No
10. Have you received a VTAG award before?
Yes No
If “Yes,” in what year(s) did you receive the award? ___________________________________
At which institution(s)? _____________________________________________________________
11. By August 2015, will you have earned a baccalaureate degree (i.e., B.A., B.S., etc)? Yes No
12.ByAugust2015,willyouhaveearnedapost-baccalaureatedegree(i.e.,M.A.,J.D.,etc)?
Yes No
13 A. What will be your level of study during the 2015-16 academic year? (Check only one)
Undergraduate Graduate (health professions) Medicine (not pre-med) and Pharmacy
B. Will this be your rst term at this level?
Yes No
14.Didyourparents/legalguardianprovide50%ormoreofyournancialsupportorclaimyouas
a tax dependent during the past year? Yes No
15 A.DoyouwishtoclaimeligibilityforVTAGbasedonyourspouse’sdomicile?
Yes No
Not Married
B. If“Yes,”doesyourspouseprovideover50%ofyournancialsupport? Yes No
16. Doanyofthefollowingcharacteristicsapplytoyou?(Placeacheckmarkbesideallthatapply)
Age 24 or older as of the rst day of the term in which you plan to enroll
Veteran or active-duty member of the U.S. Armed Forces
Ward of the court or was a ward of the court until age 18
Have legal dependents other than spouse
Post-baccalaureate student
Both parents are deceased, no adoptive or legal
guardians
[ NO P.O. BOX ]
State Council of Higher Education for Virginia 2 of 4 Update 06/14
State Council of Higher Education for Virginia
InitialApplicationDeadline:July 31, 2015
Print and submit the completed VTAG application to your institution’s nancial aid oce.
Virginia Tuition Assistance Grant Application
SECTION B: Domicile Information
If you did not check any of the characteristics in Question 16, or if you answered “Yes” to Question 15 B, complete both the
“Student” (unboxed) and“Parent/LegalGuardian/Spouse”(boxed)areasinSectionsB,C,andE.InresponsetoQuestion17,indicate
whether you are providing your parent, legal guardian, or spouse’s information in the boxed sections.
If you did check any of the characteristics in Question 16, complete only the “Student” (unboxed) areas of this application.
IMPORTANT: If you complete the portion of this application that is boxed with parental information, answer the questions based on
theparent/legalguardianfromwhomyoureceivedthemostnancialsupport.Youmayalsochoosetoprovideinformationabouta
spouse. That person also must sign and date this application.
17. You are completing the boxed areas for your: (Check only one) Father Mother Legal Guardian Spouse
For questions 18 - 22, you must answer question “B” if your response to question “A” is “No.”
Student Parent/LegalGuardian/
Spouse
18 A. Have you been employed in Virginia in the past year?
Yes No Yes No
B. If “No,” were you employed in:
C. If you answered “Not Employed” under “Student,” what are your
source(s) of nancial support?
Another State
Not Employed
Another State
Not Employed
19 A. Will (or did) you le a 2014 Virginia full- or part-year resident income
tax form?
Yes No Yes No
B. If “No,” were taxes paid to:
Another State
DidNotFile
Another State
DidNotFile
20 A. Are you a registered voter in Virginia?
Yes No Yes No
B. If “No,” are you registered to vote in:
Another State
Not Registered
Another State
Not Registered
21 A.DoyouholdavalidVirginiadriver’slicense?
Yes No Yes No
B. If “No,” do you hold a license in:
Another State
Not Licensed
Another State
Not Licensed
22 A. DoyouoperateamotorvehicleregisteredinVirginia?
Yes No Yes No
B. If “No,” is it registered in:
Another State
DoNotOwnor
Operate
Another State
DoNotOwnor
Operate
23 A. Are you an active-duty member of the U.S. Armed Forces?
Yes
No
B. If “Yes,” does your military Leave and Earnings Statement (LES) reect
Virginia withholding?
Yes No
EectivedateofchangetoVirginia:____/____/____
Attach a copy of your most recent LES.
24 A.Isyourparent/legalguardian/spouseanactive-dutymemberoftheU.S.ArmedForces?
Yes No
B. If “Yes,” does his or her military Leave and Earnings Statement (LES) reect Virginia withholding?
Yes No
EectivedateofchangetoVirginia:____/____/____
Attach a copy of his or her most recent LES.
State Council of Higher Education for Virginia 3 of 4 Update 06/14
SECTION C: Parent/Legal Guardian/Spouse Information
25. Nameofparent/legalguardian/spouse: ______________________________________________________________________
Last First Middle Initial
26.Parent/legalguardianorspouse’s
telephone numbers
Work: (_____) ______ - _________ Home: (_____) ______ - _________
27.Isyourparent/legalguardian/spouseaU.S.CitizenorPermanentResident?
Yes No
If “No,” attach a copy of his or her INS documentation, including the classication and expiration date, to this application.
28.Wherehasyourparent/legalguardian/spouselivedinthelasttwoyears?Listcurrentaddressrst.Dates must be included.
From (MM/DD/YY) To (MM/DD/YY) Street City State ZIP code
a.____/____/____ to today _____________________________ ________________ _______ ____________
b.____/____/____ to____/____/____ _____________________________ ________________ _______ ____________
c.____/____/____ to____/____/____ _____________________________ ________________ _______ ____________
SECTION D: Additional Information
29 A. Have you always resided in Virginia?
Yes No
B.If“No,”whendidyoumostrecentlymovetoVirginia?_____/_____/_______
30. When did you begin or when will you begin attending college at a Virginia institution?
(If you attended a Virginia college as an undergraduate and a graduate, please answer both)
31. A. Ifyouanswered“No”toQuestion29,didyoumovetoVirginiainorderfor
you or a member of your family to attend college?
Yes No
B. If “No, “ indicate reason for move: ____________________________________________________________________________
32. Indication your enrollment plans: (Check one.)
Enroll for both semesters (fall and spring)
Enroll for only one semester (check one):
Fall Spring
NOTE: Notify your nancial aid ocer if you are a dependent of an active-duty military member who is not claiming Virginia
domicile and they will determine if you are eligible for VTAG under the military dependent provision.
SECTION E: Certication and Signature(s)
33. I certify that the information I have provided is true. I agree to furnish the college or university and SCHEV with supporting documentation related to this applica-
tion, if requested to do so. I authorize the college to act as my scal agent for receipt of state funds; to act as SCHEV’s agent for the administration of this program,
and to release requested nancial aid and admission information to SCHEV and other VTAG participating institutions expressly for purposes of administration of
this program. I agree to notify the college or university (immediately) of any name or permanent address changes. I agree to allow SCHEV to have access to my
DepartmentofMotorVehicleandDepartmentofTaxationrecords.
___________________________________________________________________
Signature of Applicant
_____/_____/_______
Date
___________________________________________________________________
SignatureofParent/LegalGuardian/SpouseReferencedinSectionCAbove
_____/_____/_______
Date
State Council of Higher Education for Virginia 4 of 4 Update 06/14
Initial Application Deadline: July 31, 2015
Completed Applications Should Be Submitted To Your Institution’s Financial Aid Oce.
(Based on your answer to Quesiton 17)
MM DD YY
(If required to furnish parental or spousal information)
PRINT THIS FORM
Undergraduate____/_____/_____ Whichcollege?______________________________________
Graduate____/_____/_____ Whichcollege?______________________________________
MM DD YY
MM DD YY
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2015-16 TUITION ASSISTANCE GRANT PROGRAM APPLICATION (Averett College)

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