Lancaster Medical Society Foundation Student Application For Scholarship Page 2
ADVERTISEMENT
1
2Student Application for Foundation Scholarship
Page 2
Other scholarships, grants and loans applied for and/or received
_____________________________________________________________________________________
_____________________________________________________________________________________
Your income, expense and asset information for the year
January 1, 2013 to December 31, 2013. This information should be taken from a completed tax form –
filing date 4/15/2014. If married, please include joint information.
1. Adjusted gross income………………………………………………………………………..
……..
$____________
2.
Total U.S. income tax paid …………………………………………………………………. ……..
$____________
3. Non-taxable income: Social Security Benefits, Child Support, welfare, other….
$____________
4. Medical/Dental expenses not paid by insurance……………………………………………..
$____________
5. Cash, savings, bonds, stocks, checking accounts, certificates of deposit, notes
$____________
6. Number of exemptions……………………………………………………………………………………
$____________
Additional Information
Parents’ current marital status is: ____single____married____separated____divorced____widowed
Total number of family members who will be attending post-secondary school at least ½ time during the
2014 – 2015 school year, including applicant ________________________________________________
Signatures
___________________________________________________ Date Completed ____________________
Applicant’s Signature
Month
Day Year
___________________________________________________ Date Completed ____________________
Spouse’s Signature
Month
Day Year
Documents needed with this form by July 1:
1.) Please include a one-page cover letter that explains why you have chosen medicine as a career.
2.) Please include a copy of your parents’ income tax form or your own income tax form for the current
year or a joint tax form if independent from parents and married.
3.) Please include or mail separately, a transcript of your grades.
The Lancaster Medical Society Foundation will not process applications that are late or incomplete.
The Lancaster Medical Society Foundation grants scholarships to students from Lancaster County planning to
attend or who are currently attending medical school that demonstrate academic achievement, good character and
motivation, and show financial need. Awards are made without regard to race, creed, color or gender. The
scholarship recipient or recipients will be notified no later than October 31. The number of scholarships and the
dollar amount of the scholarships to be granted will be determined by the Foundation Board through careful
consideration of the funds available.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business