Fillable BERYL IVEY CONTINUING ENTRANCE SCHOLARSHIP (Brescia University College)

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BERYL IVEY CONTINUING ENTRANCE SCHOLARSHIP (Brescia University College)

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BERYL IVEY CONTINUING ENTRANCE SCHOLARSHIP
2022-2023
Deadline: February 14, 2022
To be completed in addition to the National Scholarship Application
This application is for students applying to the National Scholarship Program and wanting to be
considered for the Beryl Ivey Continuing Entrance Scholarship.
Applicant’s Information
Last Name:
First Name:
OUAC ref#:
2022-
Marital Status (circle one):
Married/common-law Single
Birth Date (dd/mm/yyyy):
School Name:
Family Information (Required for all applicants)
Number of immediate family members who live in your
Parental home, including yourself:
Number of immediate family members who live in your
Parental home attending postsecondary (in 2022-2023),
including yourself:
2020 REQUIRED
Mother’s Occupation:______________
Self Employed: Yes No s
Father’s Occupation:_______________
Self Employed: Yes No
Spouse’s Occupation:_________________
Self Employed: Yes No
Mother’s Gross Income (Line 15000 of
Income Tax Return) :
Father’s Gross Income (Line 15000 of
Income Tax Return) :
Spouse’s Gross Income (Line 15000 of
Income Tax Return) :
Mother’s EI Premiums (Line 31200 of
Income Tax Return):
Father’s EI Premiums (Line 31200 of
Income Tax Return):
Spouse’s EI Premiums (Line 31200 of
Income Tax Return):
Mother’s CPP Contributions (Line 30800
& 31000 of Income Tax Return):
Father’s CPP Contributions (Line 30800
& 31000 of Income Tax Return):
Spouse’s CPP Contributions (Line 30800 &
31000 of Income Tax Return):
Mother’s Income Tax Payable (Line
43500 of Income Tax Return):
Father’s Income Tax Payable (Line
43500 of Income Tax Return):
Spouse’s Income Tax Payable (Line 43500
of Income Tax Return):
2019 REQUIRED
Mother’s Occupation:_____________
Self Employed: Yes No
Father’s Occupation: ______________
Self Employed: Yes No
Spouse’s Occupation:_______________
Self Employed: Yes No
Mother’s Gross Income (Line 15000 of
Income Tax Return) :
Father’s Gross Income (Line 15000 of
Income Tax Return) :
Spouse’s Gross Income (Line 15000 of
Income Tax Return) :
Mother’s EI Premiums (Line 31200 of
Income Tax Return):
Father’s EI Premiums (Line 31200 of
Income Tax Return):
Spouse’s EI Premiums (Line 31200 of
Income Tax Return):
Mother’s CPP Contributions (Line 30800
& 31000 of Income Tax Return):
Father’s CPP Contributions (Line 30800
& 31000 of Income Tax Return):
Spouse’s CPP Contributions (Line 30800 &
31000 of Income Tax Return):
Mother’s Income Tax Payable (Line
43500 of Income Tax Return):
Father’s Income Tax Payable (Line
43500 of Income Tax Return):
Spouse’s Income Tax Payable (Line 43500
of Income Tax Return):
Self-Employment: If a parent or spouse was self-employed in any of the years requested above, we will require
a copy of the business statements that relates to that particular taxation year. Please be prepared to submit if
requested.
Documentation of Parental / Spousal Income: Copies of your parent / spouse’s personal income tax return
notice of assessments may be requested. We will contact you if we require this documentation.
Family Asset Information (Required) - Values as of February 2022. If not
applicable enter $0.
Mutual Funds (estimated FMV
@ Feb/22):
Parents: Student:
GICs (at Feb 2022
):
Parents:
Student:
Total Bank Account Balances –
chequing, savings etc (at Feb 202
2):
Parents: Student:
Term Deposits: (at Feb 202
2)
Parents: Student:
Stocks (estimated FMV @ Feb 2022):
Parents: Student:
Bonds (face value): (at Feb 2022)
Parents:
Student:
Total Value of Investments Held
Outside Canada:
Parents: Student:
Other:
Parents: Student:
RRSP’s
(at Feb 2022)
Parents:
Student:
_____________
Total amount of RESP’s $_____________
Amount of RESP to be used for the 2022/2023 academic year? (Estimate is ok)
$ Real Estate (Attach additional sheet if required)
Parental Primary Residence
Address:
Student’s Personal Primary
Residence (if different from
Parental)
Address:
Recreational Property / Other
Type:
Address:
Market Value (from latest Property
Assessment):
Market Value (from latest Property
Assessment):
Market Value (from latest Property
Assessment):
Mortgage Owing:
We do not own this property.
We rent.
Mortgage Owing:
Property not owned.
Rented.
Mortgage Owing:
Non-Registered Investments - Documents supporting the value of all non-registered investments may be
required. Please be prepared to submit investment statements as applicable. We will contact you if we require
this documentation. If you hold financial interests (shares) in private businesses/corporations please include all
audited financial statements.
Real Estate – Copies of the latest property assessment (not tax bill) are required. Please submit a copy of
the most recent property assessment with your application.
STATEMENT COMPONENT (Please attach your statement to the application)
Please describe in 500 - 700 words on how your activities contribute to your home, community or
school and impact the lives of others. Include: how you feel you meet the financial need
component – including any family/financial circumstances.
SUMMER ACTIVITY COMPONENT
Please describe how you spent the majority of your summer and whether you were able to accumulate
any summer savings to help fund your education.
Summer 2021
Please describe how you will be spending the majority of your 2022 summer and whether you will
be able to accumulate any summer savings to help fund your education.
I understand that if any information is found to be untrue or inaccurate, this application may be considered cancelled and
any money received as a result will have to be returned. If additional financial resources (e.g. sponsorships, external
awards/scholarships, service medical agreements) become available after this application is signed, you must disclose the
information to our office during the application process and if you are a successful recipient of this scholarship
Date Signature
The information on this form is collected under the authority of the University of Western Ontario Act, 1982, as amended,
and is needed to process your application, and decide your eligibility for the Schulich Scholarship. Registrarial Services
may disclose to the award donor, who may use your information in publications associated with the bursary/award, and
share with the appropriate Faculty, Department(s), and School(s) the following student personal information: name, address,
biographical data, faculty, academic programs, and any other information that confirms criteria to the donor of the bursary
or award. If you have any questions or concerns about the collection, uses, and disclosure of this information by the
University, please contact Manager (Student Central), Registrar’s Office, Western Student Services Building, Room 1120,
Western University, London, ON, N6A 3K7, Tel: 519-661-2111, extension 84863.
Questions about this application: Norma Merino
nmerino@uwo.ca
Submit application: Upload your application and statement (as 1 document) through the online National
Scholarship application – in section: Beryl Ivey Scholarship
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BERYL IVEY CONTINUING ENTRANCE SCHOLARSHIP (Brescia University College)

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Completed 8 March 2022

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