To be submitted to your local school with application or mailed directly to Jean Olson (GIV, 25 Hubbard Street, Montpelier VT, 05602). Print out and complete this form, or obtain one from your high school counselor.

First Name: ___________________________ MI: _____

Last Name: ___________________________________

Address: _______________________________________

City: ______________________________

State: ______

Zip Code: __________

Social Security Number: _______________

School: __________________________________________

Introduction

The Governor's Institutes of Vermont conducts "need-blind" admissions. This means that the information on this form has no bearing on the admission process, and is only considered AFTER the student has been admitted. All financial material submitted will be kept strictly confidential.

If your family's per capita income is $9,500 or below, you are eligible to apply for scholarship aid. If you would like to request financial assistance, please provide information concerning the items listed below so that we can determine your eligibility for financial support.

If your parents are separated or divorced, each parent must submit a copy of the first page of their 2002 tax return. Be sure to include the expected contribution from each parent in the Family Resources section of this form. We cannot consider your financial aid application without this information.

Please keep in mind that we determine financial awards immediately after the application deadline of April 1st. Therefore, if you are requesting an award, make sure that the financial information we need is either submitted with your application or mailed directly to the Institute office by April 1. Our goal is to ensure that no qualified and accepted applicant will be denied admission to the Institutes because of financial need.

This form is also available through your high school counselor or our office (25 Hubbard St., Montpelier, VT, 05602, (802) 229-4757).

PARENTS:

1. 2002 Adjusted Gross Income: _________________________________
   
   
2. Father's 2002 Wages: _____________________________
   
   
3. Mother's 2002 Wages: _____________________________
   
   
4. 2002 nontaxable income (i.e., child support, pension plan contribution, unemployment, etc.): _____________________________
   
   
5. Medical/dental expenses not paid by insurance (not premiums): ______________
   
   
6. U.S. income taxes paid in 2002 (do not include state and local taxes): __________
   
   

• 2002 income from wages, salaries, and tips: ____________________
  
  
• 2002 unearned income (including social security benefits): _____________
  
  
• Current value of applicant savings and investments: ________________
  
  
• Value of trust fund of which applicant is a beneficiary (give details on separate paper): ___________
  
  
• Make and year of applicant's car: ______________________________
  

• How many people currently reside in your household? (Include yourself, your parents, brothers and sisters, and any individuals who receive at least half of their support from the family.): _________
  
  
• Please explain any sources and amounts of nontaxable income, any unusual expenses, educational or other debts or expenses, or special circumstances. (Use extra sheets if necessary.):
  
  ________________________________________________________________
  
  

Please estimate the money you will have available to pay your Governor's Institute costs:

1. Funds from parents (distinguish contributions from mother and father if your parents are divorced or separated). Remember, we require financial information from both parents in the case of divorce: ______________
   
   
   
2. Funds from applicant's earnings: _____________
   
   
3. Funds available from applicant's savings and investments: _____________
   
   
4. Assistance from friends or relatives: _____________
   
   
5. Total family resources: _____________

Student's Signature: _______________________________________ Date: ________

Please Print Student Name: ______________________________________________

Parent's Signature: ______________________________________ Date: ________
(Or person responsible for Student Tuition, if different)

Please Print Parent/Guardian Name: ___________________________________

If you have any questions about the Governor's Institutes programs, contact:

Jean Olson, Executive Director
The Governor's Institutes of Vermont
25 Hubbard Street
Montpelier, Vermont 05602 Telephone: (802) 229-4757
E-mail: giv@sover.net
www.giv.org