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CHITIMACHA SCHOLARSHIP PROGRAM (Chitimacha Tribe of Louisiana)

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Chitimacha Student Aid Program Application
December 6, 2006
1
CHITIMACHA SCHOLARSHIP PROGRAM
P.O. Box 661/ 230 Chitimacha Loop
Charenton, LA 70523
Phone: (337) 923-2463 Fax: (337) 923-6848
Email: tahrad@chitimacha.gov
APPLICATION PACKET
MUST BE COMPLETED/SUBMITTED: MANUALLY
Electronic Signatures will not be accepted.
COLLEGE/UNIVERSITY
PROPRIETARY SCHOOL
VOCATIONAL/TECHNICAL
Semester/Quar./Etc.:
Year:
Date:
Name:
Soc. Sec. #
Date of Birth:
Phone #
Email:
Address:
City/State/Zip:
Signature:
By submission of this application, whether manually or electronically, I agree to abide by the rules
and regulations as established under the Chitimacha Scholarship Program, and any policy changes
or Board of Education directives that may be implemented during this term.
Chitimacha Student Aid Program Application
December 6, 2006
2
ESTIMATED EXPENSES
Semester/Quarter/Etc.:
Year:
HOUSING INFORMATION
During the Semester/Quarter/Etc. for which funding is being requested;
I will be living at home or with the person who owns the dwelling in which the
space I am renting is located.
I will be renting or leasing living space other than as stated above.
Current Rental /Lease Agreement must be submitted which indicates; the
monthly rental fee, you as a tenant and the number of other persons
residing in the unit.
I certify that my living arrangements are as stated and understand that my housing
allowance will be prorated to the number of people listed on my housing documents such
as lease, rental, or dorm documentation as well as to the number of credit hours I
complete this term.
Signature:
Date:
EDUCATION INFORMATION
Chitimacha Student Aid Program Application
December 6, 2006
3
Semester/Quarter/Etc.:
Year:
LEVEL OF EDUCATION
GED
Date Obtained:
High School Diploma
Date Obtained:
Attended and/or Attending College
Number of terms funded
by this program:
Associate Degree
Date Obtained:
Bachelor Degree
Date Obtained:
Other
What and date Obtained:
TYPE OF DEGREE/CERTIFICATION BEING SOUGHT
Certification:
Year expected to Obtain:
Associate Degree:
Year expected to Obtain:
Bachelor Degree:
Year expected to Obtain:
Other:
Year expected to Obtain:
COLLEGE/UNIVERSITY/PROPRIETARY SCHOOL ATTENDING
Name of Institution:
Mailing Address:
City/State/Zip Code:
Phone #’s Financial
Aid
Office/Registrars Office:
Major:
Current Classification:
Number of
Hours
Scheduled:
CERTIFICATION
(PLEASE READ CAREFULLY BEFORE SIGNING)
Semester/Quarter/Etc.:
Year:
I hereby certify that the information I have provided to the Chitimacha Scholarship
Program is true and correct to the best of my knowledge. I understand that should the
information be found to be false or misleading, I will be required to repay all funding
received and I will be suspended from the Scholarship Program. I also understand and
agree that should I fail to apply the scholarship/grant funds in accordance with this
agreement or to comply with the terms and conditions of the Scholarship Program
guidelines, then I will be in default of the scholarship/grant agreement. In that event, I
hereby understand that I will be suspended from the program and I agree that interest
will accrue on the funds received by me from the date of receipt until paid at the
contractual rate of one and on-half (1½%) percent per month.
I also consent to the release of information to necessary agencies to complete my
financial aid package for semesters for which I have received funds through the
Scholarship Program. I agree to provide a copy of or to provide for the release of my
grades or transcript to the Chitimacha Scholarship Program Office at the end of each
academic semester/quarter for which I have received an award through the Chitimacha
Scholarship Program.
I agree to attend the College/University, Proprietary, Vocational, Technical, Trade School
named and to work toward the objective I have stated. If I find it necessary to withdraw
before the end of the period of the award, I agree to consult with my college counselor
and to notify the Chitimacha Scholarship Program Office of my intentions before
withdrawing or within 10 working days of withdrawal. I understand that I will be
required to pay back all or a portion of funds to the Chitimacha Scholarship Program as
established in the Chitimacha Scholarship Program Guidelines.
Signature:
Date:
FOR OFFICE USE ONLY
Received By:
Date:
CHITIMACHA STUDENT AID PROGRAM
P.O. Box 661/ 230 Chitimacha Loop
Charenton, LA 70523
Phone: (337) 923-2463 Fax: (337) 923-6848
Email: tahrad@chitimacha.gov
Chitimacha Student Aid Program Application
4
D
ecember 6, 2006
Chitimacha Student Aid Program Application
December 6, 2006
5
RELEASE OF INFORMATION
NOTICE: This form must be downloaded, executed and returned to the Chitimacha
Scholarship Office as part of your application.
TO:
ADDRESS:
hereby authorize the release of requested information including but not limited to: financial, academic,
attendance, housing and any other pertinent information that may be required by the Chitimacha
Scholarship Office for the
Agents of the above named business, institution, etc. are authorized to cooperate fully with the contact
person for the Chitimacha Scholarship Program: Tahra Demarco, Acting Scholarship Coordinator
SIGNATURE:
DATE:
I UNDERSTAND THAT BY SIGNING THIS RELEASE, I AM IN NO WAY RELIEVED OF THE RESPONSIBILITY OF
PROVIDING THE REQUIRED DOCUMENTS AS ESTABLISHED IN THE PROGRAM GUIDELINES.
CHITIMACHA STUDENT AID PROGRAM
P.O. Box 661/ 230 Chitimacha Loop
Charenton, LA 70523
Phone: (337) 923-2463 Fax: (337) 923-6848
Email: tahrad@chitimacha.gov
Semester/Quarter/Term/Etc.:
I,
(Insert Name)
Chitimacha Student Aid Program Application
December 6, 2006
6
COMMUNITY INVOLVEMENT PROGRAM AGREEMENT
Semester/Quarter/Etc.:
Year:
STUDENT: In accordance with the revised Scholarship Program Guidelines as adopted
on September 20, 2006, a new student pay back program is scheduled to become
effective January 1, 2007, specifically, the “Community Involvement Program”. As
stated therein, “students who are currently operating under the “payback” policy and
have accrued hours in advance of usage, will be allowed to continue to match hours to
dollars until all advanced hours are used. Once that is done this student would then
participate in Phase I of the new program. Students who are currently operating under
the “payback” policy and owe hours will begin the Community Involvement Program
Phase I”. You are required to sign this agreement and return it to this office along with
your application.
I realize that by my accepting a Scholarship from the Chitimacha Scholarship Program I
am agreeing to participate in the service pay-back program as deemed applicable in
accordance with the revised program guidelines
SIGNATURE:
DATE:
CHITIMACHA STUDENT AID PROGRAM
P.O. Box 661/ 3291 Chitimacha Trail
Charenton, LA 70523
Phone: (337) 923-2463 Fax: (337) 923-6848
Email: tahrad@chitimacha.gov
Chitimacha Student Aid Program Application
December 6, 2006
7
TOTAL EXPENSES:
FINANCIAL AID DATA SHEET
Name of Student:
Semester/Quarter,
Etc. and year:
Soc. Sec. #
Phone #’s
Name and Address of
Institution:
Number of Hours
Scheduled:
To Be Completed by Financial Aid Officer
EXPENSES FOR THE SEMESTER
Tuition/Fees:
Date Due:
Room/Board:
Books:
AWARDS FOR THE SEMESTER
Student has not applied for financial aid as yet.
A determination has not been received on this student’s financial aid application
as of this date.
The student has been awarded assistance as follows;
$
PELL
$
SEO
$
WORK/STUDY
$
OTHER
Signature of Financial
Aid Officer:
Date:
(Name) Please Print:
Phone#:
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CHITIMACHA SCHOLARSHIP PROGRAM (Chitimacha Tribe of Louisiana)

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Completed 27 January 2021

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