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 applicant’s 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 Guardian’s 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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