 
  
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
  
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
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


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 
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The Corporation for Ohio Appalachian Development
David V. Stivison Appalachian Community Action Scholarship Fund
A
pplicant Checklist
Please see the attachment in the mailed application packet or refer to our website and write down the name and
address of your local community action agency:
_______________________________________ This is where you will be sending your
completed application materials.
_______________________________________
SENDING APPLICATIONS DIRECTLY
_______________________________________ TO COAD WILL DELAY PROCESSING.
_______________________________________
When submitting an application for consideration for a David V. Stivison Appalachian
Community Action Fund Scholarship, please make sure you have included the following:
_____ Application for Financial Assistance (2 pages)
_____ Household Income Statement and Verification Form (1 page)
_
____ Income documentation (ie. tax returns or paycheck stubs, etc.)
_____ Counselor/Principal Evaluation Form (1 page)
_____ High School Transcript
_____ Proof of acceptance by an accredited 2-year or 4-year institution
of higher education.
MARK EACH ITEM THAT YOU ARE SUBMITTING AND INCLUDE THIS CHECKLIST WITH
YOUR APPLICATON MATERIALS.
PLEASE NOTE THAT OMISSION OF ANY OF THESE DOCUMENTS COULD
PREVENT YOU FROM BEING CONSIDERED FOR SCHOLARSHIP ASSISTANCE.
The Corporation for Ohio Appalachian Development
David V. Stivison Appalachian Community Action Scholarship Fund
APPLICATION FOR FINANCIAL ASSISTANCE
Students: We consider it your responsibility to see that this information is complete in every detail and is submitted (postmarked) by
April 1 to the appropriate Community Action Agency in your area.
You must submit the following material:
1. Household Income Statement and Verification Form: Please complete and submit the financial information statement
attached. This form must be signed by your parent or legal guardian. Non-traditional students must complete and sign this form.
2. Application Form: Please note the application must be signed by you and your parent/legal guardian (unless you are a non-
traditional student).
3. Counselor/Principal Evaluation Form: Remind your counselor that a transcript must accompany this application.
REMEMBER All information must be submitted (postmarked) to the appropriate local Community Action Agency by April 1 to be
considered.
Please type or print
General Information:
Full Name:_________________________________________________________________________ Gender: _____ _____
Last First Middle Initial Male or Female
Address: ___________________________________________________________ Ohio ___________ ___________________
Number & Street/Route/Box # City Zip Code Area Code and Telephone #
County of Residence: _________________________________ Email address: ________________________________________
Date of Birth: _____________________ Marital Status: _____________________ SSN (last four digits) : _xx-xxx-___________
High School Attended: _______________________________________________________ Graduation Date: ________________
Parent or Guardians Full Name: _______________________________________________________________________________
Last First Middle Initial
Name and Address of College or University you plan to attend: _______________________________________________________
Planned major field of study: _____________________________________________
You may attach additional pages if there is not adequate space for you to complete the remaining required information.
List jobs (including summer employment) you have held:
Job Title Employer Employment Dates Hrs. Per Week
________________________________ _____________________________ _____________ To _____________ ___________
________________________________ _____________________________ _____________ To _____________ ___________
________________________________ _____________________________ _____________ To _____________ ___________
List Activities/Organizations in which you have participated during High School (School, Church and Civic):
________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
APPLICATION FOR FINANCIAL ASSISTANCE Page 2
List any honors or awards you received during high school:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List all other financial assistance you have received or for which you have applied for the next academic year:
Type/Name of Assistance Date Applied Date Awarded Amount
____________________________________________ ___________________ ____________________ ____________________
____________________________________________ ___________________ ____________________ ____________________
____________________________________________ ___________________ ____________________ ____________________
Please explain any special circumstances the Scholarship Selection Committee should take into consideration:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Briefly explain your reasons for seeking a college education and the goals you have set for your future:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I confirm the information on this application is accurate and
complete to the best of my knowledge. I understand that
incomplete documentation or failure to submit all required
forms listed in the instructions will disqualify the applicant.
As the Applicant’s parent or guardian, I confirm that the
Applicant has my permission to apply for the COAD David V.
Stivison Appalachian Community Action Scholarship. I also
verify that the financial and academic information provided is
accurate and complete to the best of my knowledge.
_______________________________________________ _______________________________________________
Applicant’s Signature Date Parent/Guardian’s Signature Date
click to sign
signature
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signature
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The Corporation for Ohio Appalachian Development
David V. Stivison Appalachian Community Action Scholarship Fund
COUNSELOR/PRINCIPAL EVALUATION FORM
(To be completed by school personnel)
Student’s Full Name: _______________________________________________
This information should reflect the student’s status at the conclusion of the most recent grading period of the senior year:
Grade Point Average ________ of a possible ________ points Rank in class _____________
ACT composite score ______________________ or SAT scores __________________________
The following information should reflect your personal observation of the student:
Please rate this student as to his/her overall effort exhibited during the school year:
Outstanding _________ Above Average ___________ Average ___________
Please rate this student as to his/her inclination to succeed in post secondary education:
Outstanding _________ Above Average ___________ Average ___________
Please rate this student as to his/her character:
Outstanding _________ Above Average ___________ Average ___________
Based on your knowledge of this student, please indicate your perception of his/her need for financial assistance:
Definite Need _________ Possible Need___________ Questionable Need___________
Please use the space provided for additional remarks and/or to explain any special circumstances the Scholarship Selection
Committee should take into consideration (you may use additional paper if necessary):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
PLEASE REMEMBER TO ATTACH A TRANSCRIPT OF GRADES TO THIS FORM
________________________________________ __________________________________ ________________
Printed Name of Counselor/Principal Title Date
_______________________________________________________________ ________________________________________________________________
Signature of Counselor/Principal School District and/or County
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signature
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The Corporation for Ohio Appalachian Development
David V. Stivison Appalachian Community Action Scholarship Fund
HOUSEHOLD INCOME STATEMENT AND VERIFICATION FORM
Instructions: This form is to be completed by the applicants parent or legal guardian unless the applicant is a non-traditional student, in
which case the form is to be completed by the applicant. In either case, this form must be completed and submitted with the other
application information.
To be eligible for this scholarship, the applicant must reside in a household with a total annual income at or below 200% of the current
federal poverty guidelines.
Full Name: Traditional Student
(High school senior) or Non-Traditional Student ______
(check one)
Parent or Guardians Full Name
(if traditional student):________________________________________________________
(check one)
Gross Household Income Information:
List all persons who have lived in the household during the last calendar year and identify all sources and gross amounts of income for
that calendar year. All sources of income must be documented and copies of the documentation must be attached to this form and
submitted with the application. Examples of acceptable documentation include tax returns, benefit notification letters, pay stubs, etc.
Full Name Birth Date Source of Income # of Mos. Recd 12 Month Total
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________
TOTAL ANNUAL HOUSEHOLD INCOME =
I certify that the total annual household income shown above is complete and accurate. I understand that household income means all
income received by all persons residing in the household, including, but not limited to Social Security benefits, Veterans benefits,
Alimony, Child Support, Interest, State Unemployment benefits, Workers Compensation benefits, Strike benefits, cash Public
Assistance benefits, Wages and Tips.
I verify that all statements and items of documentation submitted on and with this form are true, correct and complete and I realize that
I may be held liable under Federal and State laws for making any knowingly false or fraudulent statements.
_____________________________________________________ ____________________
Signature of Parent, Guardian or Non-Traditional Student Date
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signature
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