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					Mrs. Aviva Harpaz Menaheles

Linda Peck Principal

INCOME AND EXPENSES
1. Please attach a copy of your current income tax return(s). If the student’s father and mother file separately or are separated or divorced, please forward returns of both parents and step-parents (each can be under separate cover). If a tax form was not filed, your sources of income must be recorded (see #3). Principal wage earner’s yearly salary or income $ Other parent’s yearly salary or income $ Step-parent and/or non-custodial parent yearly salary or income $ 3. Untaxed or other income for the calendar year. a. Child support (for all children) b. Alimony payments received or household expenses paid by the separated or divorced spouse in lieu of alimony c. Social Security benefits d. Aid to Families with Dependent Children or AFDC–record total for year e. Food stamps, yearly total f. Other
EXPENSES: Rent or Mortgage Utilities Installment Payments (car, etc) Savings Insurance Support Payments Transportation Food Clothing Household Supplies Medical/Dental Recreation/Entertainment Miscellaneous Tuition (other schools) Other TOTAL EXPENSES

TUITION ASSISTANCE APPLICATION: PAGE 1 OF 4

2.

$ $ $ $ $ $

Monthly

Yearly

Tel. 757-627-BINA (2462) • Fax. 757-627-2461 • 420 Spotswood Avenue • Norfolk, VA 23517 • www.binahighschool.com

Mrs. Aviva Harpaz Menaheles 4. Do you own your home? Yes Fair Market Value Per property tax assessment Per your estimate Monthly mortgage payment Property taxes Insurance Unpaid principal mortgage balance If your residence is not owned, record your rent 5. Do you own other property? Yes Fair market value less mortgages Location Monthly mortgage payment – principal and interest Insurance Property taxes Unpaid principal mortgage balance 6. Do you own or partially own any business? Yes No If yes, please complete the following: a. Total capital value of your ownership/partial ownership interest in the business b. Your share of the last full year earnings of the business 7. $ $ $ $ No $ No $ $ $ $ $ $ $

Linda Peck Principal

TUITION ASSISTANCE APPLICATION: PAGE 2 OF 4

$ $

Please list value of holdings in other investments. a. Savings accounts $ b. Money market funds $ c. Other investments (to include but not limited to trust funds, CDs, stocks, bonds, etc.) $ d. Cash value of life insurance $ e. Current value of pensions (including IRAs, 401Ks, employer sponsored pensions, etc.) $ f. Trusts of which you or your children are the beneficiaries $ Have you incurred significant debt because of serious illness, disability, or accident? Yes If yes, please explain No

8.

9.

Are there any unusual family circumstances that should be considered by BINA High School in awarding financial assistance? Yes No If yes, please explain

Tel. 757-627-BINA (2462) • Fax. 757-627-2461 • 420 Spotswood Avenue • Norfolk, VA 23517 • www.binahighschool.com

Mrs. Aviva Harpaz Menaheles

Linda Peck Principal

Personal Data:
Father: Last Name Home Phone Address City Occupation/Position Employed by: E-mail address State First Name MI Age Apt. # Zip Work Phone # years Self-employed? (Y/N)

Mother: Last Name Home Phone Address City Occupation/Position Employed by: E-mail address

Application # First Name MI Age Apt. # State Zip Work Phone # years Self-employed? (Y/N)

TUITION ASSISTANCE APPLICATION: PAGE 3 OF 4

Marital status (circle one): Single Married Separated Divorced Divorced/Remarried Widowed 2008-09 (Current School Year): Name of each child in your family Applied for Financial Aid? (Y/N)

Marital status (circle one): Single Married Separated Divorced Divorced/Remarried Widowed

Tuition Assistance Request (attach additional sheet if necessary):
Name of School/ Childcare Grade in 2008-089 Full tuition of school Aid amount received in 2008-09 Net amount paid in 2008-09

2009-10 (Next School Year): Name of each child in your family Applied for Financial Aid? (Y/N)

Name of School/ Childcare

Grade in 2009-10

Full tuition of school

Aid amount received in 2009-10

Net amount paid in 2009-10

Tel. 757-627-BINA (2462) • Fax. 757-627-2461 • 420 Spotswood Avenue • Norfolk, VA 23517 • www.binahighschool.com

Mrs. Aviva Harpaz Menaheles

Linda Peck Principal

I (we) attest to the accuracy of this application

TUITION ASSISTANCE APPLICATION: PAGE 4 OF 4

Parent Signature

Date

Parent Signature

Date

PARENT CHECKLIST FOR BINA HIGH SCHOOL TUITION ASSISTANCE APPLICATION You have applied for enrollment for the 2009-10 year. You have paid the $100 application fee (for new students only) You are enclosing a copy of your signed, filed IRS 1040 income tax return. Both parents in a family, where parents are divorced or separated, provided financial information. If not, attach a copy of the court order. You signed this financial aid form.

Tel. 757-627-BINA (2462) • Fax. 757-627-2461 • 420 Spotswood Avenue • Norfolk, VA 23517 • www.binahighschool.com


				
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