2020-2021 APPLICATION WORKSHEET
State Form 56495 (R2 / 7-20)
COMMISSION FOR HIGHER EDUCATION
This worksheet is
provided to assist local schools and community organizations in collecting information required to submit an official online application on
behalf of eligible students for Indiana’s 21st Century Scholars Program. THIS INFORMATION MUST BE SUBMITTED ONLINE AT WWW.SCHOLARTRACK.IN.GOV BY JUNE
30, 2021 TO BE CONSIDERED BY THE SCHOLARS PROGRAM.
School
Community Organization
THIS IS NOT AN OFFICIAL ENROLLMENT FORM. The school or organization listed below is requesting permission to submit an application on behalf of a potential
21st Century Scholar student. The organization listed below agrees to take full responsibility for the timely submission of the application, for the
safeguarding of sensitive information contained on this form, and for the destruction of this form after the online application has been submitted.
Organization name: Organization contact:
Telephone number: E-mail address:
* Indicates information required to submit 21st Century Scholar application.
Student Information *Current Grade Level *Student Gender
□ 7th □ Male
□ 8th □ Female
*Student First Name Middle Initial *Student Last Name □ Not Provided
Racial Identity Hispanic, Latino or Spanish Origin?
□ White □ Chinese □ Vietnamese □ Other Pacific Islander □ None □ Cuban □ Other
□ Black or African American □ Filipino □ Other Asian □ Samoan □ Mexican, Mexican American, Chicano
□ American Indian or Alaska Native □ Japanese □ Native Hawaiian □ Other □ Puerto Rican
□ Asian Indian □ Korean □ Guamanian or Chamorro
*Date of Birth
(month, day, year)
*Social Security Number Student Test Number (STN)
*Mailing Address
(number and street)
IN
*City State *ZIP Code *County
Type
□ Cell
*E-mail Address *Telephone Number
□ Home
□ Work
Current Middle School High School Student Will Attend
Student’s 21st Century Scholars Pledge
For application to be considered, a student must agree to the following pledge by signing below. As a Scholar, you pledge to:
Complete the Scholar Success Program, which includes activities at each grade level in high school and in college to help you plan, prepare and pay for college.
Graduate from a state-accredited high school with a minimum of a Core 40 diploma and a cumulative grade point average (GPA) of at least 2.5 on a 4.0 scale.
Not use illegal drugs, commit a crime or delinquent act, or consume alcohol before reaching the legal drinking age.
File the Free Application for Federal Student Aid (FAFSA) by April 15 as a high school senior and each year thereafter until you graduate from college.
Apply to an eligible Indiana college as a high school senior, and enroll as a full-time student within one year of high school graduation.
Maintain Satisfactory Academic Progress (SAP) standards established by my college.
Complete thirty (30) credit hours each year you are in college to stay on track toward earning your degree on time.
□ I understand that I must be an Indiana resident (as determined by the permanent residence of my parent or legal guardian), a U.S. citizen or eligible
non-citizen, and meet all other eligibility requirements.
(Your signature is required for this application to be submitted online on your behalf.)
*Student Signature *Date (month, day, year)
Household Information
Parents must report the
type and amount
of
ALL
sources of income received in the household during the most recent tax year. If applying after December 31, 2020, please
use 2020 gross income. If there are more than five (5) household members, list additional members on a separate sheet and attach to this worksheet.
Who should I include as members of my household?
ou must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses.
What is considered to be my household income?
Household income is any money received on a recurring basis, including gross earned income. Gross earned income means all money received before such
deductions as income taxes. Income includes but is not limited to: earnings from work, net income from self-owned businesses (cannot be less than $0),
unemployment and worker’s compensation, welfare, child support, alimony, and retirement and disability benefits.
What is considered “Other” income?
Regular contributions from persons not living in household
Income from estates, trusts, investments
Net rental income, annuities, net royalties
Military allowance for of
-post housin
Cash withdrawal from savings
Interest/dividends
Any other income
Total Number of Members in Household: _________________________________
Student Income
$ $ $ $
Work TANF Child Support Alimony
$ $ $ $
Disability Self Employment Social Security Other
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signature
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