Fillable PROGRAM APPLICATION Tennessee Investments Preparing Scholars (State of Tennessee)

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PROGRAM APPLICATION Tennessee Investments Preparing Scholars (State of Tennessee)

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  • 0 check-boxes
  • 104 other fields

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File type: PDF

U.S.A. forms for State of Tennessee

BROWSE STATE OF TENNESSEE (TN) FORMS

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TR-0451
(Rev. 7/2020)
- 1 - RDA-2516
PROGRAM APPLICATION
Tennessee Investments Preparing Scholars
A Program of the State of Tennessee Treasury Department
P.O. Box 55597 w Boston, MA 02205-5597
Local: 615-741-1502 w Toll-Free: 1-855-386-7827 w Fax: 615-401-6816
Email: tn.stars@tn.gov w Website: www.tnstars.com/ps
Use this application to apply for the State of Tennessee’s TIPS higher education savings matching grant program.
• Complete and mail, with this form, a TNStars™ Account Application for any beneciary listed in Section 2
of this application that does not already have a TNStars™ account.
• Make sure to list ALL members of your household related by marriage, birth or adoption in Section 3.
• Your TIPS Application and contributions must be postmarked by June 30, 2021.
• Tax return/transcript must accompany the TIPS Program Application.
• To qualify for the TIPS higher education savings matching grant program, your total Federal Adjusted
Gross Income must be less than the amount shown below (depending on the size of your family):
2020
Total Federal Adjusted Gross Income*
Persons in Family or Household
Family of 1
=
$ 31,900
Family of 2
=
$ 43,100
Family of 3
=
$ 54,300
Family of 4
=
$ 65,500
Family of 5
=
$ 76,700
Family of 6
=
$ 87,900
Family of 7
=
$ 99,100
Family of 8
=
$110,300
For family units of more than eight (8), add $4,480 for each additional person.
*Beginning January 1, 2021 through June 30, 2021, the 2020 tax return may
be provided for income verication. As such, from January 1, 2021 until
June 30, 2021, TNStars™ participants may use either the 2019 tax return or
the 2020 tax return.
Information relative to household income is required to be submitted with this application for the TIPS
higher education savings matching grant program. You may provide a copy of the 2019/2020 tax return
for each income earner in the household or you may include a transcript of your 2019/2020 tax return.
Please refer to TIPS Program Description for details regarding terms and conditions.
TR-0451
(Rev. 7/2020)
- 2 - RDA-2516
PROGRAM APPLICATION
1. Account Owner Information
List the individual who will be the Account Owner of the TNStars™ account(s). Please print clearly, one leer per box, preferably
in capital leers and black ink.
First Name MI Last Name
Street Address Apartment / Unit
City State Zip Code
Email Address
— —
Telephone Number (dayme)
Tennessee Investments Preparing Scholars
A Program of the State of Tennessee Treasury Department
P.O. Box 55597 w Boston, MA 02205-5597
Loc
al: 615-741-1502 w Toll-Free: 1-855-386-7827 w Fax: 615-401-6816
Email: tn.stars@tn.gov w Website: www.tnstars.com/ps
Mail this form and any other required documents to one of the addresses below. Do not staple.
For Regular Mail:
Tennessee Investments Preparing Scholars
P.O. Box 55597
Boston, MA 02205-5597
For Overnight or Registered Mail:
Tennessee Investments Preparing Scholars
95 Wells Avenue, Suite 155
Newton, MA 02459-3204
TR-0451
(Rev. 7/2020)
- 3 - RDA-2516
2. Participant (Beneciary) Information
List the beneciary(s) whose educaon expenses will be paid from the account(s). You may list more than one beneciary if their
accounts are owned by the same Account Owner(s). Include the TNStars™ account number for each beneficiary who already has
a TNStars™ account. The beneficiary must reside with the participant and be 15 years of age or younger. Please print clearly,
one letter per box, preferably in capital letters and black ink.
Beneciary #1:
First Name MI Last Name
/ /
Date of Birth (mm/dd/yyyy)
Current TNStars™ Account Number
Beneciary #2:
First Name MI Last Name
/ /
Date of Birth (mm/dd/yyyy) Current TNStars™ Account Number
Beneciary #3:
First Name MI Last Name
/ /
Date of Birth (mm/dd/yyyy) Current TNStars™ Account Number
Beneciary #4:
First Name MI Last Name
/ /
Date of Birth (mm/dd/yyyy) Current TNStars™ Account Number
Beneciary #5:
First Name MI Last Name
/ /
Date of Birth (mm/dd/yyyy) Current TNStars™ Account Number
-
-
-
-
-
TR-0451
(Rev. 7/2020)
- 4 - RDA-2516
3. Household Members’ Information
Informaon relave to household income is required to be submied with this applicaon for the TIPS higher educaon savings
matching grant program. You may provide a copy of the 2019/2020 tax return for each income earner in the household or you may
include a transcript of your 2019/2020 tax return.
To request a free transcript of your tax return to be mailed to you, call 1-800-908-9946. Using the automated IRS system, request:
• Tax Form Number - 1040 series
• Type of Transcript - ‘Return‘ transcript
• Year Requested - 2019 or 2020
A separate tax return (or transcript of tax return) is required for each member living in the household who is not listed on a joint
tax return. For joint lers, only one tax return or transcript must be provided.
Number of Household Members Number of Income Earners in Household
1. $
,
Account Owner’s First Name Last Name Annual Income
You must list all individuals related by marriage, birth or adopon, including children, living in the household. Please print clearly,
one leer per box, preferably in capital leers and black ink.
2. $
,
Household Member’s First Name Last Name Annual Income
Relaonship to Account Owner Yes No
3. $
,
Household Member’s First Name Last Name Annual Income
Relaonship to Account Owner Yes No
4. $
,
Household Member’s First Name Last Name Annual Income
Relaonship to Account Owner Yes No
Did this individual le
a separate tax return?
Did this individual le
a separate tax return?
Did this individual le
a separate tax return?
TR-0451
(Rev. 7/2020)
- 5 - RDA-2516
4. Signature
By signing this applicaon, the undersigned ceres that all the informaon contained herein is accurate and that the undersigned
has read and understands the TIPS Program Descripon. The undersigned also aests that the household income is within the
stated applicable range listed on page 1. Any informaon provided on this applicaon that is missing or incorrect may aect the
processing of this applicaon and could impact parcipaon in the TIPS higher educaon savings matching grant program.
Account Owner’s Signature Date
Approved By Date
5. $
,
Household Member’s First Name Last Name Annual Income
Relaonship to Account Owner Yes No
6. $
,
Household Member’s First Name Last Name Annual Income
Relaonship to Account Owner Yes No
7. $
,
Household Member’s First Name Last Name Annual Income
Relaonship to Account Owner Yes No
8. $
,
Household Member’s First Name Last Name Annual Income
Relaonship to Account Owner Yes No
For Ocial Use Only
Did this individual le
a separate tax return?
Did this individual le
a separate tax return?
Did this individual le
a separate tax return?
Did this individual le
a separate tax return?
3. Household Members’ Information
(continued)
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PROGRAM APPLICATION Tennessee Investments Preparing Scholars (State of Tennessee)

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Completed 27 January 2021

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