2015 Financial Assistance App

FINANCIAL ASSISTANCE
APPLICATION SUMMER 2015
Book and/or Transportation Subsidy
Please return this application with any additional documents to your EAOP Representative or mail it directly to the
EAOP Office (2150 Kittredge St. Suite 3A, Berkeley, CA 94720-1060) by March 26, 2015. All students who submit
a completed application by the due date and are accepted to one of the EAOP Summer Programs will be considered
for a book and/or transportation subsidy.
Students will be notified if they have been awarded a book and/or transportation subsidy by the end of April. Please
note that students awarded a transportation subsidy may still be expected to contribute a maximum of two dollars a
day to the overall cost of transportation this summer.
ELIGIBILITY CRITERIA
Student’s eligibility is determined by membership in a family unit whose annual income falls within these guidelines.
•
Household Size
Annual Income
2
< $40,000
3
$40,001 - $46,250
4
$46,251 - $52,500
5
$52,501 - $58,750
6
$58,751 - $65,000
For each additional family members, add $6,250.
REQUIRED DOCUMENTS
Please submit a copy of one of the following documents as proof of income. Do NOT submit original versions, as they
will not be returned. CROSS OR BLACK OUT ANY SOCIAL SECURITY NUMBERS. FAILURE TO SUBMIT THE
FOLLOWING DOCUMENT(S) WILL RESULT IN DISQUALIFICATION FOR FINANCIAL ASSISTANCE.
•
2014 Income Tax Return
o 2013 will also be accepted if you have yet to file your 2014 income tax
o W-2s will NOT be accepted
SUBMITTING YOUR APPLICATION
The deadline for the Financial Assistance Application is on March 26, 2015. Applications can be submitted in one of two
ways:
1. Turn it in directly to your EAOP representative at your school.
2. Mail (postmarked by the deadline) it to the EAOP office at:
Early Academic Outreach Program
Financial Assistance Application
2150 Kittredge St. Suite 3A
Berkeley, CA 94720-1060
Please print legibly. All fields must be completed. Incomplete applications will not be processed
Student Information
First Name: _____________________ Middle Name: ________________ Last Name: _______ _______________
Address: _____________________________________________________________________________________
City: ____________________________________, CA
Gender:
☐ Female
Zip Code: ____________________________________
☐ Male
Home Phone: (______)____________________________ Cell Phone: (______)___________________________
Email address: ________________________________________________________________________________
High School: _________________________________________________________________________________
EAOP Summer Program
Please check the box of the summer program to which you are applying.
☐ Pre-College Academy (PCA) (9th & 10th grade)
☐ UC Berkeley Summer Sessions (11th grade)
Transportation
Please check the form of transportation you will use to get to the UC Berkeley campus this summer.
☐ BART: ___________________________
☐ AC Transit
(home station where you will board)
Statement of Certification
I acknowledge that all of the information provided on this form and the accompanying document(s)
is true. I realize that failure to provide accurate information may result in denial of financial
assistance to the student.
Student Name (PRINT): ____________________________________________________________
Student Signature: _________________________________________________________________
Parent/Guardian Name (PRINT): ____________________________________________________
Parent/Guardian Signature: ________________________________________________________
Date: _______________________