52 Broadway New York, N.Y.

10004 (212) 539-0500

INSTRUCTIONS
FOR COMPLETING THE U.F.T. COLLEGE SCHOLARSHIP FUND APPLICATION

Incomplete Applications will be Ineligible.

General Instructions
1. The deadline for schools to mail the application is January 31. Your high school
may indicate an earlier date for submission of the application to them.

2. Applications which are incomplete at the time of selection may not be considered. 3. All supplementary documents must contain your name and high school.
The Albert Shanker College Scholarship Fund of the United Federation of Teachers award application includes questions that enable us to determine the eligibility of applicants. Some applicants have unusual home or family situations which cannot be completely described by answering only these questions. If you have an unusual or extraordinary situation, it is your obligation to make it clear to the Selection Committee. Your explanation of exceptional circumstances must be specic and include documentary proof (photocopies only) whenever it applies. DOCUMENTARY PROOF, IN ADDITION TO THAT WHICH IS SPECIFICALLY REQUIRED ON THE APPLICATION, MAY INCLUDE SUCH ITEMS AS: Adoption Papers Alien Registration Card Bank Books Birth Certicates Business or Corporate Tax Returns Court Orders (ALL PAGES) Death Certicates Divorce Decrees (ALL PAGES) Deeds to Property Guardianship Decrees Last Will and Testament Letters on Ofcial Letterheads NaturalizationPapers Passports Property Tax Assessment and Mortgage Statements Separation Agreements (ALL PAGES) Unemployment Form 1099-G Visas

ALBERT SHANKER COLLEGE SCHOLARSHIP FUND UFT

Specic Instructions
Some items are self-explanatory. Those which may require additional explanations are listed below. Item Number Front Cover 3 Explanation (Directions to Applicant) This direction suggests topics which you may use to try to convince the Selection Committee to select you as an award winner. You may select additional categories if you wish. Be brief but complete. Remember that you are competing for a $5,000 award. If you cannot submit good reasons why you should be selected as an award winner, the Selection Committee probably will not nd reasons to select you.

Inside Cover-8 According to federal law, you must have a Social Security number. 9 &10 &11 Family Data 12 &13 List basic information on the adult(s) presently responsible for you. If you are living with a relative other than your parent, explain the relationship. Also explain any unusual nancial support arrangements.If your natural parent(s) is deceased, please supply the following information under item 27: Name of parent(s), occupation during the last full year of employment, date of death, tax return during the last full year of employment if within the last ve years. Also include a copy of the last will and testament. If unemployed at present, state duration of employment period and also include normal occupation. Explain in detail under item 27. Submit photocopies of the Unemployment Form 1099-G. If parent is self-employed, nature and description of business should be included in item 27. If a separate business tax form is led, a copy of that return, with all schedules should be included. PARENTS MARITAL STATUS: Please check box, insert dates and submit documents where applicable. MinorsBrothers and sisters not living with you should be listed under item 27. Ex.: Away at college, living with relatives, etc. Step and foster brothers and sisters should be included here. If they are students, please give name or number of school. If employed, state occupation and employer. List name(s) of sibling(s) who received UFT scholarships in prior years. State the year they won. List any musical, artistic or special talents you have. List your hobbies. If you attended any schools outside the New York City public school system, specify where, what school and include school records where available.

12c & 13c 12e & 13e 14 & 14a 15

15a 16 17

Financial information This category must include a complete tax return on which you are declared as a dependent. All information in this section refers to the 2010 calendar year. If parents are separated or divorced, tax returns of both must be supplied. All formal decrees, including property settlement, alimony, custody and child support copies must be submitted. Be sure to submit photocopies of all tax returns led, both front and back portions, and W-2 forms. Include 1099 forms. Include copies of all schedules cited on the tax return. For example, Schedule B, C, D or E, etc..

ALBERT SHANKER COLLEGE SCHOLARSHIP FUND UFT

18 19 19a.

Give 2010 information. All 2010 information must be documented and included with this application and include your name and Social Security number. Compute annual amount in each category. Include dates where specied. Documentation required. Photocopy of I.D. card and photocopy of family Budget Plan can be obtained from your human resource ofce. On Budget Plan, please indicate approximate date of issuance. A statement of 2010 Social Security benets letter can be obtained by contacting your local Social Security ofce. Please indicate effective dates of benets. Proof of veterans benets are obtained from the Veterans Administration. The documents should show nature and amount of benets. Please indicate effective dates and benets. A photocopy of the current Unemployment Form 1099-G must be submitted. Court order, divorce decree or other suitable documents. A copy of both parents complete tax returns must be submitted. (Alimony is included as taxable income.) List here, and provide documentation, on proceeds of tax exempt securities, income from other countries, income from others who support the applicant, non-taxable pensions. Full statements of explanation should be added. Value of assets are to be listed under item 25. This item refers to the house you live in. Any other property is listed under item 25. Explain partnerships or co-ownerships. If home, co-op, condominium or land, include a copy of the annual mortgage statement from the bank and a copy of your property tax assessment. This is the document used to prove taxes and interest paid when ling tax returns. You own the house even if it is not fully paid for. Explain partnership or business car. If more than one car, explain under item 27. Details and documents must be included. Send Schedule E of your familys tax return. Itemize, giving details and documents, all family assets not listed in 20 to 24. List stocks and bonds, money market funds, mutual funds, annuities and real estate. Send Schedule D. Provide details of ownership, dates obtained, purpose of ownership. Give current fair market value. This list must be attached to the application. Failure to list all assets will result in disqualication. Explain under item 27 any arrangements whereby assets, income or dependencies are transferred or shared with family, friends or other associates. Describe any unusual or temporary nancial arrangements. BOTH SIGNATURES ARE REQUIRED. If born outside the United States, give exact date of arrival and detail circumstances and present status. The deadline for mailing this application is January 31. Be sure that you turn it in to the schools guidance ofce far enough in advance of that date to ensure that the school has time to complete its portion of your application. Many schools set their own earlier deadline. If you have difculty obtaining any documentation by the deadline date, le the application without it. Attach a note explaining what items are missing and when you expect to have them in. Then be sure to send them. We will accept additional information until the selection process begins in February.

b. c. d. e. f.

20.

22 24 25

26 27

*NOTE: Remind your counselor to enclose your high school transcript.

ALBERT SHANKER COLLEGE SCHOLARSHIP FUND UFT

Determining Financial Eligibility

To estimate your nancial eligibility for this program, you must: 1. Ascertain the proper number of dependents to which your family is entitled. The number used for income tax purposes is the one you should use here, except that you cannot use the extra exemptions that IRS permits. Add up all family income that will be included in lines 18 and 19 of the application. This is the non-taxable income of all family members, and taxable income of parents or guardians only. Find the proper column for your family size in the table below, and compare the gure arrived at in 2 above with that in the table. If your familys income is equal to, or less than that shown, you are nancially eligible based on income considerations. DEPENDENTS MAXIMUM FAMILY GROSS INCOME $30,076 $35,308 $39,852 $42,922 $45,869 $48,817 $51,764 $54,712 $57,659 $60,606

2. 3.

1 2 3 4 5 6 7 8 9 10

This information is supplied for your estimate only. Other factors, such as family assets and resources and unusual circumstances, may eliminate some otherwise eligible applicants. Ofcial eligibility will be determined by the Fund.

Incomplete Applications will be Ineligible A FINAL CAUTIONARY NOTE

LOOK OVER YOUR APPLICATION:
1. Have you completed all parts?.......................................... n Yes n No 2. Have you submitted all required documents?................. n Yes n No (Financial, transcript, references, etc.) 3. Have you taken care that all unusual situations are....... n Yes n No explained in detail, so that the Fund understands your personal and nancial situation? 4. Are you eligible to apply for federal nancial aid.......... n Yes n No (PELL)*?

IF THE ANSWER TO ANY OF THESE QUESTIONS IS NO, YOU SHOULD NOT APPLY FOR THIS AWARD.
*Applicants applying for this scholarship must be eligible to apply for federal nancial aid (PELL) in order to receive this award. We require a copy of all pages.

ALBERT SHANKER COLLEGE SCHOLARSHIP FUND UFT

COLLEGE:

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TRANSCRIPTS 2011 2013 RECEIVED ALBERT SHANKER SEL. COM. COLLEGE SCHOLARSHIP FUND

NON-TAX

DEP

AS

of the United Federation of Teachers

52 BROADWAY, 7TH FLOOR NEW YORK, NY 10004

INV

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APPLICATION FOR COLLEGE FUND - 2013 SCHOLARSHIP PROGRAM APPLICATION FOR COLLEGESCHOLARSHIP SCHOLARSHIP FUND2011 SCHOLARSHIP PROGRAM
The United Federation of Teachers in cooperation with the New York City Board of Education sponsors an annual scholarship program for High School Seniors from low income families graduating from New York Citys Public High Schools. The award, a $5,000 scholarship payable at the rate of $1,250 per year, will be based on the students record as contained in the application form. The award is for undergraduate study only. To be eligible for this program, a familys total income from all sources must not exceed the low income criteria established by the Fund. (A table relating family size to maximum permissible income is included in the accompanying instruction sheet. In addition to income, family assets and resources are considered in determining eligibility.) The Albert Shanker College Scholarship may be used at any college accredited by one of the six regional accrediting agencies which agree to use the award in a manner approved by the Fund. An independent committee of educators will review the applications and submit a list of recommended award winners to the Albert Shanker College Scholarship Award Committee. The determination of the Award Committee is final on all questions. Awards will be announced in April. Special certificates will be issued to the High Schools for presentation to award winners at the schools commencement ceremonies. APPLICANTS ARE REQUIRED TO APPLY FOR FINANCIAL ASSISTANCE PROVIDED BY THE PELL GRANT PROGRAM OF THE FEDERAL GOVERNMENT. PLEASE READ ITEM #26 BEFORE COMPLETING THIS APPLICATION.
DIRECTIONS TO APPLICANT

With this application you received an instruction sheet. Read the instructions for each item as you fill out the application.
() Check below when you have completed each step. 1. Fill in completely all applicable items from 1-26. Please PRINT IN INK OR TYPE all information. Item 27 is to be used to provide the Selection Committee with any additional information necessary to answer items 1-26. The Fund may request additional information from applicants. 2. You should enclose RECOMMENDATIONS from the UFT Chapter Chairman, teachers or other individuals who have knowledge of your qualifications. 3. Please enclose (PRINT IN INK OR TYPE) an essay which you feel will promote your selection. Your essay must include information such as (1) Your extra curricular activities; (2) Your educational or professional goals; (3) Jobs you have held; (4) Community or school service; (5) Your leadership roles in school and (6) Special home or family situations. Additional sheets may be used. 4. Make sure that you have enclose this application, the required copies of tax returns, your essay and all recommendations in the self-addressed envelope provided. It will help keep your documents together and safe from loss. Be sure to affix sufficient postage. Do not send original documents since they cannot be returned. 5. Bring the application with the supporting documents to your guidance counselor for completion of the schools portion by . The schools office will mail the application. DIRECTIONS TO THE COUNSELOR Please check the application to ensure that the applicant has completed his portion of the application and included supporting financial documents and recommendations. Please do not staple. 1. Complete items 28-31. 2. Your comments will be greatly appreciated. 3. PLEASE HAVE A COPY OF THE APPLICANTS TRANSCRIPT ENCLOSED. 4. The application with all supporting documents must be mailed in the self-addressed envelope by January 31, January 31, 2011. 2013.

1. LAST NAME ______________________________________________________

FIRST NAME ____________________________________________

MIDDLE NAME______________________________________________

2. DATE OF BIRTH ______________________________________ 3. SEX _________________________________________________ 4. HIGH SCHOOL ______________________________________________________ 5. ADDRESS

NUMBER

STREET

APT.

NY
BOROUGH (Be specific: Give full address such as Jamaica, St. Albans, etc.) ZIP

6. PHONE
Persons Name

7. AGE
Phone

If you have no phone, please give the number of a relative, friend or neighbor who can get a message to you.

8. SOCIAL SECURITY NUMBER 9. CELL PHONE NUMBER 10. E-MAIL ADDRESS 11. HIGH SCHOOL CODE
ASK YOUR COLLEGE ADVISOR OR COUNSELOR FOR THIS CODE (EX. Q415= BENJAMIN N. CARDOZO HS)

FAMILY DATA
CIRCLE ONE CIRCLE ONE

12.

FATHER*, STEPFATHER OR GUARDIAN

NAME AGE

13.

MOTHER*, STEPMOTHER OR GUARDIAN

NAME AGE

12a.
SOC. SEC. NO.

13a.
SOC. SEC. NO.

12b.
STREET ADDRESS

13b.
STREET ADDRESS

CITY

STATE

ZIP

CITY

STATE

ZIP

12c.
OCCUPATION (even if presently unemployed)

13c.
OCCUPATION (even if presently unemployed)

12d.
EMPLOYER

13d.
EMPLOYER

12e.
EMPLOYERS ADDRESS

13e.
EMPLOYERS ADDRESS

12f. CHECK IF SELF-EMPLOYED 14.

13f. CHECK IF SELF-EMPLOYED

*If either natural parent is deceased or unknown, give details on back. Information under items 12 & 13 should concern living individuals.

PARENTS CURRENT MARITAL STATUS: SINGLE MARRIED SEPARATED ________ DIVORCED ________ WIDOWED ________
DATE DATE DATE

14a. If separated or divorced submit legal separation or divorce decree 15. BROTHERS AND SISTERS LIVING WITH YOU (See instructions page 1) NAME AGE OCCUPATION OR SCHOOL (Specify)

15a. Name(s) of sibling(s) who received prior U.F.T. Awards: Year Received: Year Received: Year Received: 16. 17. SPECIAL TALENTS: HOBBIES:
REMINDER: APPLICANTS APPLYING FOR THIS SCHOLARSHIP MUST BE ELIGIBLE TO APPLY FOR FEDERAL FINANCIAL AID (PELL) IN ORDER TO RECEIVE THIS AWARD.

FINANCIAL INFORMATION INCOME (Be sure to use instruction sheet when completing this section)
With this application you MUST submit:

1. 2. 3. 4. 5.

Photo copies of complete 2009 2011 Federal Income Tax Returns (Forms 1040, 1040A, or 1040 EZ) for each member of the family who filed such a report. You must include all schedules. A copy of all W-2 and 1099 Forms received by family members. Proof of income if family is supported in whole or in part by Veterans benefits, alimony or pension fund. 2011 Award Letter if supported in whole or in part by Social Security. Photo copy of 2009 Photo copies of I.D. card and Family Budget if supported in whole or in part by Public Assistance.
ADJUSTED GROSS INCOME (From line 37 of IRS Form 1040 or line 21 of IRS 1040A) (You must answer all that apply.) If not applicable enter NA
FATHERS EARNINGS $ MOTHERS EARNINGS $ TAXABLE TOTAL $
2011 2009

18.

19.

NON TAXABLE INCOME Annual Amount

a. b. c. d.

For proof required in each category, see instructions.

$ ___________ $ ___________ $ ___________ $ ___________ e. Child Support f. Other: (See instructions) ___________________ NON TAXABLE TOTAL TOTAL ANNUAL INCOME: $ ___________ $ ___________ $ ___________ $ ___________

Public Assistance: Case no. _________ From _______ To _______ Social Security (For all family members) From _______ To _______ Veterans Benefits: From _______ To _______ Unemployment Insurance: Unemployed From _______ To _______

ASSETS (Be sure to use instruction sheet when completing this section) (You must answer all that apply.) 20. Does your family own: (Check all appropriate categories)
_______ Single family home? _______ Two family home _______ Three or more family home? ______ A Co-op? ______ A Condominium? Purchase price $___________________ Date of Purchase ________ Present Value $ ____________________ Original Mortgage $___________________ Unpaid Mortgage $_____________ Monthly Mortgage Payment $____________ If a Co-op or Condominium, what is your monthly carrying charge? $____________ Does your family rent? Yes No What is your monthly rent? $______________________ Does your family own a car? Yes No Make ________________ Year ___________ Balance of Car Loan $__________________________________ Cash in Checking Account $_____________________________________ Savings Account $_____________________________________________________
Does your family own a business? Yes No Type _________________________ Location ___________________ Date of Purchase _________ Total Value $___________________________________ Other Family Assets (Investments, Real Estate, etc.)? Yes No Describe in detail in item 27.

21. 22. 23. 24. 25.

26. WE AFFIRM THAT TO THE BEST OF OUR KNOWLEDGE THE

INFORMATION REPORTED ON THIS AND THE ENCLOSED DOCUMENTS IS COMPLETE AND CORRECT. IT IS SUBMITTED WITH THE INTENTION THAT IT IS TO BE RELIED UPON BY THE ALBERT SHANKER COLLEGE SCHOLARSHIP FUND SELECTION COMMITTEE IN DETERMINING THE APPLICANTS ELIGIBILITY FOR A SCHOLARSHIP AWARD. THE ALBERT SHANKER COLLEGE SCHOLARSHIP FUND HAS OUR PERMISSION TO VERIFY THE INFORMATION REPORTED AND COMMUNICATE WITH THE APPLICANTS PARENT OR GUARDIAN AS NECESSARY IN THE CONSIDERATION OF THIS APPLICATION. FALSE OR MISLEADING INFORMATION WILL RESULT IN DISQUALIFYING THE APPLICANT OR REVOKING THE SCHOLARSHIP.

I UNDERSTAND THE IF I AM SELECTED AS AN ALBERT SHANKER SCHOLARSHIP RECIPIENT, I MUST APPLY FOR FEDERAL FINANCIAL AID.

SIGNATURE OF APPLICANT

SIGNATURE OF PARENT OR GUARDIAN DATE

SCHOLARSHIP INFORMATION

Note: Have you completed item 27 on the back of this application?

28. SCHOLASTIC AVERAGE ______________ 28a. RANK IN CLASS __________ 28b. PERCENTILE STANDING __________ (6 TERMS) (6 TERMS) 29. GRADUATION IS ANTICIPATED FEBRUARY JUNE SUMMER 30. SPECIAL PROGRAMS COLLEGE DISCOVERY COLLEGE BOUND OTHER (SPECIFY) __________________ PRINCIPAL OR COUNSELOR 31. ON A SEPARATE SHEET OF PAPER, PLEASE WRITE A SUMMARY APPRAISAL OF THE CANDIDATE, ASSESSING HIS ACADEMIC AND PERSONAL QUALITIES. INCLUDE SIGNATURE ANY SPECIAL QUALITY OR TALENT HE POSSESSES. TITLE ALSO PLEASE CITE ANY SPECIFIC EVENT OR SPECIAL CIRCUMSTANCES WHICH GIVE INSIGHTS INTO THE STRENGTHS AND WEAKNESSES OF THE APPLICANT. PLEASE INFORM US IF THE STUDENT IS DISABLED OR HAS A SERIOUS HANDICAP.
DATE:

PHONE PHONE/EXT. SCHOOL SEAL OR OFFICIAL SCHOOL STAMP

FAX

27. EXPLANATIONS AND STATEMENT OF APPLICANT. (Explanation which apply to a specific item should be preceded by its number.)

INCOMPLETE APPLICATIONS WILL BE INELIGIBLE.