NAME: SOCIAL SECURITY #:

PLACE OF EMPLOYMENT: FULL/PART TIME? (Give percent please)

ADDRESS CITY: STATE:

I. Anticipated Finances of the Assistance Fund Project:

A. Expenses:
Registration.................................... $
Travel .............................................. $
Lodging ............................................ $
Other (please give details) ....... $
........................................................… $

B. Have funds been requested from your school district? Yes No

C. Portion of cost from other sources (list below)................................ $

D. Portion of cost you will assume:.......…………..................…………. $

II. Your annual income: .............. Last Year ...........This Year

A. Wages ........................................... $ ..................... $.......................

B. Dividends .......................................$ ..................... $.......................

C. Interest ..............................$ ..................... $.......................

D. Other than A, B, C ............$ ..................... $.......................

E. Non taxable income ...........$ ..................... $.......................

IIl. Spouse's income..........................$ ..................... $.......................

IV. TOTAL ..........................................$ ..................... $.......................

V. Federal Income tax you paid ......$ ..................... $.......................

Vl. Federal Income tax of spouse ..$ ..................... $.......................

VII. Number of dependents .....................

Vlll. A Short statement of any special financial circumstances may be detailed on the back. Please include copies of the two most recent income tax returns you have filed

These facts are correct to the best of my knowledge.

Signature

Date