Fillable Scholarship-hse Community Education High School Equivalency Scholarship Request Form

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Scholarship-hse Community Education High School Equivalency Scholarship Request Form

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U.S.A. forms for Hudson Valley Community College

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HUDSON VALLEY COMMUNITY COLLEGE
HIGH SCHOOL EQUIVALENCY
SCHOLARSHIP REQUEST FORM
Student Name: ______________________________________________________________________
SS# _______________________________ Date of Birth:
Address:____________________________________________________________________________
Telephone (Home) _____________________________ (Cell) _______________________________
Email address:_____________________________________
DETERMINATION OF INCOME ELIGIBILITY GUIDELINES
Use the chart below to determine if you are eligible for a scholarship and circle appropriate household size
Please submit a copy of your 2018 Income Tax Return or a paystub along with this form.
HOUSEHOLD SIZE
INCOME
Year
Month
Week
1
22,459
1,872
432
2
30,451
2,538
586
3
38,443
3,204
740
4
46,435
3,870
893
5
54,427
4,536
1,047
6
62,419
5,202
1,201
7
70,411
5,868
1,355
8
78,403
6,534
1,508
For each additional
family member add
+7,992 +666 +154
* If your household income exceeds the amount listed for your household size please send in your request anyway. If we
have additional funds to award we may extend the eligibility requirements.
If awarded a scholarship I acknowledge I am responsible for submitting a valid NYS Certificate of Residence (if
needed), and am responsible for any materials fees. If I do not officially withdraw from the High School
Equivalency course I will forfeit future scholarship eligibility.
Student Signature Date
Additional information that you feel should be considered in determining need:
PLEASE RETURN TO: Hudson Valley Community College
Office of Community Education
80 Vandenburgh Avenue Email – communityed@hvcc.edu
Troy, NY 12180 Phone (518) 629-7339 Fax (518) 629-8103
To the best of my knowledge, the information herein provided is accurate in all particulars.
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Scholarship-hse Community Education High School Equivalency Scholarship Request Form

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Completed 3 November 2019

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