Financial Need Information Form (*optional)

Please complete in full

The Merrick Foundation scholarships that are based on financial need are marked with an (*) on the
requirements pages. If financial need information is not provided, you will not be considered for scholarships
based on financial need. 

Name:
Permanent Address:
City:
State:
Zip:

1) List all Scholarships/Grants/Financial Aid you have received to date for the 2010-2011 school year.

Received Amount Received Amount

2) Will it be necessary for you to be gainfully employed while in school?
Yes  No.  If so, estimate hours per week that it will be 
necessary for you to work:

3) Please list anticipated sources of income & costs below:

Income Amount
Savings
Earnings
Student Loans
Work Grants
Parental Help
Other:
Cost Amount
Tuition
Fees
Books
Room/Board
Personal Expenses
Other:

4) Father's Occupation:
    Mother's Occupation:


5) List name and age of each dependent in your family (Line 6c of parent's 2009 Form 1040 - Do not include parents.):

Name Age Name Age

 

6) Number of dependents in family who will be attending college full-time 2010-2011.


7) Were you claimed as a dependent on your parent(s)/guardian(s) federal income tax in:
2007: Yes No
2008: Yes No
2009: Yes No

8) Please complete the following:

Parent's Adj Gross Income Number of Dependents Student's Adj
Gross Income		 Number of Dependents
2007
2008
2009

To the best of my knowledge, the above information furnished above is true.

Please print out this form and sign and date below. 

Mail completed form to:
Merrick Foundation, Inc.
P.O. Box 206, Central City, NE 68826

 
____________________________________________              ______________
Student Signature (Required)                                                      Date

____________________________________________              ______________
 Parent or Guardian Signature (Required)                                      Date


Please print out two copies of this form. One to sign and mail in, and the
other to retain for your records. For your security, please hit the "Clear" button
when finished and return to the application by using the "back" button in your browser.

Contact Information:

Merrick Foundation, Inc.
P.O. Box 206, Central City, NE 68826
Phone: 308.946.3707 Fax: 308.946.3049
General Information: merrickf@hamilton.net