Fill - Free fillable Academic Advisement Programs Application (The Chickasaw Nation) PDF form

Page 1 of 3 Form no. 04900 CS-EDU Rev. 5/2018

Academic Advisement Programs Application

Program Eligibility Guidelines

The student tutoring reimbursement and credit recovery programs funded by the Chickasaw Nation provide at-risk

Chickasaw students assistance to improve their academic performance. By completing this application, the

student whose name appears below with the signature of his parent/legal guardian, makes application for

reimbursement to the student tutoring reimbursement or credit recovery programs provided by the Chickasaw

Nation.

Forms need to be turned in before tutoring commences.

Applicant Information: (If not completing online, please type or print clearly in ink)

Student name (first, middle, last, suffix):

Student’s mailing address – street, city, state and zip:

Students’ physical address – street, city, state and zip:  Same as Mailing

Phone: Home: Cell:

Birth date:

Email:

SSN:

Classification (check one):

Grades:  1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

Parent / Legal Guardian:

Parent / legal guardian’s name (first, middle, last, suffix):

Parent / legal guardian’s email:

Parent / legal guardian’s mailing address – street, city, state and zip:  Same as Applicant

Parent / legal guardian’s physical address – street, city, state and zip:  Same as Mailing

Phone: Home: Work: Cell:

Relationship:

Birth date:

Employer:

By signing below, you certify that tutoring has been received for the current academic classification:

Parent / legal guardian signature:

Date:

Program applying for:  Student Tutoring Reimbursement Program

 Credit Recovery Program

Education Division / Supportive Programs

300 Rosedale Road / Ada, OK 74820 / (580) 421-7711 / Fax (580) 272-1224

Bill Anoatubby

Governor

Page 2 of 3 Form no. 04900 CS-EDU Rev. 5/2018

REFERRAL:

This portion must be completed by an acceptable school representative (superintendent, principal,

teacher or counselor) confirming the student’s enrollment. You are responsible for having this portion

completed. Please do not return to our office with this portion incomplete. Incomplete applications cannot

be processed.

This certifies that is currently enrolled as a full-time student at

Student name

School name School accreditation number

Is student on an IEP or 504 plan?

School address  Yes  No

School official’s comments stating subject and tutoring/credits needed:

Signature of school representative Title Date

===================================================================================================================

The Chickasaw Nation Supportive Programs Office and the applicant agree to strictly maintain the confidentiality of all information disclosed hereunder, or any amendments thereto.

The parties agree that the information contained in said application shall be considered “Confidential Information” and shall not be disclosed to third persons, except upon written

consent of the applicant or as otherwise required by law.

Tutoring Reimbursement Program Guidelines:

 Chickasaw students in 1st through 12th grades attending a state-accredited school or enrolled in a school

which meets state academic curriculum standards for high school graduation.

 Forms needed before tutoring commences:

 Academic advisement programs application Form 04900 with school’s referral defining academic

assistance needed, completed and signed by the parent/guardian and an acceptable school official;

 Child’s current report card showing a grade of “C” or lower in the area requested for tutoring;

 If applicable, copy of an IEP or 504 Plan showing child’s name and school-recommended

accommodation;

 W-9 for parent/guardian for the reimbursement;

 Documentation showing tutor is qualified - documentation can be in the form of:

 Teacher certification

 Resume

 Professional credentials

 Letter of recommendation from an acceptable school official and most recent report card for those

tutors still in college or high school. For those in high school, tutoring candidates cannot be lower

than a 10th grader.

 Tutor cannot be a relative of the child or parent/guardian.

 Tutoring is limited to one hour per day per approved subject area for tutoring.

 Reimbursement is for tutoring in basic skills only – English-based reading, writing, math or science.

 If the subject is geography, social studies or history and the school official makes a referral based on low

reading comprehension for this subject, then this subject would fit into the reading area for eligibility along

with a report card reflecting the C or below grade criteria for eligibility for tutoring in this subject area.

 Once tutoring has been approved and the tutoring allowance assistance log Form 04900L has been

submitted, a copy of the child’s current progress report must be submitted every six weeks to show

improvement under the selected tutor’s assistance. If no progress has been shown in the six-week period,

the tutor selected will no longer be an eligible tutor.

 Tutoring allowance assistance logs must be turned in monthly. If multiple children from a family are being

tutored, all logs are to be submitted at the same time.

 Maximum tutoring allotment per year is $600 per child.

 Reimbursement will not be provided for school tuition, online course fees, book rental, materials/supplies

fees, advanced placement courses or concurrent college level classes.

Page 3 of 3 Form no. 04900 CS-EDU Rev. 5/2018

Credit Recovery Program Guidelines:

 Chickasaw students in 9th through 12th grades attending a state-accredited school or enrolled in a school

which meets state academic curriculum standards for high school graduation.

 Payment will be made directly to the school which is providing credit recovery.

 Forms needed before credit recovery approval:

 Academic Advisement Programs Application Form 04900 with school’s referral signed by an

acceptable school official.

 Child’s current report card showing a grade of “F”

 W-9 for school

 School’s credit recovery application

 If for some reason the child should not complete the credit recovery class, the child will be on suspension.

 Maximum credit recovery per year is $600 paid directly to the school.

Form W-9

(Rev. November 2017)

Department of the Treasury

Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

▶

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the

requester. Do not

send to the IRS.

Print or type.

See Specific Instructions on page 3.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the

following seven boxes.

Individual/sole proprietor or

single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

▶

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check

LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is

another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that

is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions)

▶

4 Exemptions (codes apply only to

certain entities, not individuals; see

instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid

backup withholding. For individuals, this is generally your social security number (SSN). However, for a

resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other

entities, it is your employer identification number (EIN). If you do not have a number, see How to get a

TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and

Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

Employer identification number

–

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am

no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because

you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,

acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments

other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign

Here

Signature of

U.S. person

▶

Date

▶

General Instructions

Section references are to the Internal Revenue Code unless otherwise

noted.

Future developments. For the latest information about developments

related to Form W-9 and its instructions, such as legislation enacted

after they were published, go to www.irs.gov/FormW9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an

information return with the IRS must obtain your correct taxpayer

identification number (TIN) which may be your social security number

(SSN), individual taxpayer identification number (ITIN), adoption

taxpayer identification number (ATIN), or employer identification number

(EIN), to report on an information return the amount paid to you, or other

amount reportable on an information return. Examples of information

returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual

funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross

proceeds)

• Form 1099-B (stock or mutual fund sales and certain other

transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest),

1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident

alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might

be subject to backup withholding. See What is backup withholding,

later.

Cat. No. 10231X

Form W-9 (Rev. 11-2017)

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