Income Verification Form - 2016-2017
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2EDCHOICE SCHOLARSHIP PROGRAM
2016-2017 INCOME VERIFICATION FORM
Income Verification is one step in the scholarship application process. Your child must also be enrolled at a participating school. The Income Verification
Process is important for some families to determine if they meet low income requirements of the scholarship program. If you are a new or renewal applicant of
the Scholarship and you qualify for low income status, you will not have to pay tuition above the amount of the scholarship. If you are a new or renewal applicant
of the EdChoice Expansion Scholarship, you must complete the income process every year to receive a scholarship award.
Helpful tools can be found on the scholarship website at: If you have more than one child applying for a scholarship, only one
income verification form is needed. The scholarship office is not able to return original documents to you; please send only copies. The form and copies of
income documents must be mailed to the address below by the deadline July 31, 2016:
Ohio Department of Education, Scholarship Program Office
25 S. Front Street, Mail Stop 309 Columbus, Ohio 43215
#1
NAME:
FIRST
LAST
MIDDLE
MARITAL STATUS
GENDER:
M
F
DATE OF BIRTH:
LAST FOUR DIGIT SS#:
ADDRESS:
N
RECEIVES INCOME:
Y
CITY:
OHIO
ZIP CODE:
E-MAIL:
PHONE:
Name of Private school where your child is enrolled
LIST ALL MEMBERS OF YOUR HOUSEHOLD
Please make a copy of this page if more space is needed.
#2
NAME:
FIRST
MIDDLE
LAST
LAST FOUR DIGIT SS#:
F
M
GENDER:
DATE OF BIRTH:
RELATIONSHIP TO YOU:
Y
N
RECEIVES INCOME:
SCHOLARSHIP STATUS (CHECK ONE):
RENEWAL:
NEW:
NA:
#3
NAME:
FIRST
MIDDLE
LAST
F
M
LAST FOUR DIGIT SS#:
GENDER:
DATE OF BIRTH:
RELATIONSHIP TO YOU:
Y
RECEIVES INCOME:
N
SCHOLARSHIP STATUS (CHECK ONE):
RENEWAL:
NA:
NEW:
#4
NAME:
MIDDLE
LAST
FIRST
M
F
DATE OF BIRTH:
GENDER:
LAST FOUR DIGIT SS#:
RELATIONSHIP TO YOU:
SCHOLARSHIP STATUS (CHECK ONE):
N
Y
RECEIVES INCOME:
RENEWAL:
NEW:
NA:
#5
NAME:
FIRST
LAST
MIDDLE
DATE OF BIRTH:
GENDER:
F
LAST FOUR DIGIT SS#:
M
RELATIONSHIP TO YOU:
N
SCHOLARSHIP STATUS (CHECK ONE):
RECEIVES INCOME:
Y
NEW:
RENEWAL:
NA:
Click here for page 2
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ODE.SSEO.NEO.IncomeVerifForm.1.25.2016
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