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2006 1040Ez Form document sample
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The North Carolina State Firemen’s Association
HERBERT D. GARMON SCHOLARSHIP AWARD
IN THE AMOUNT OF ONE THOUSAND FIVE HUNDRED DOLLARS
to attend a two year community college or trade school
2008 APPLICATION FORM
Submitted by the Fire Department in County
As Chief of this Fire Department, I understand that only one Herbert D. Garmon Scholarship Application in
the amount of One Thousand Five Hundred Dollars for every 100 firemen in my department may be
submitted. Submissions of more than one application for this scholarship will result in the disqualification
of all candidates submitting this application from this departments.
_________________________________
(Must be Original Signature)
Section A: Yourself
1. Applicant’s First Name Applicant’s Last Name
2. Applicant’s Mailing Address
3. Applicant’s Phone Number 4. Last 4 Digits of SS#
5. Are you a firefighter with this department? Yes No
If so, how long have you been a firefighter?
Is this Department a Member of the NCSFA? Yes No
Section B: Your Plans
6. Have you applied to a college of university? Yes No
7. If so, what is the name of the college or university to which you have applied? If more
than one, please list all.
8. As of the date of this application, have you been accepted by a college or university to
which you applied? Yes No
Section C: Educational Background
9. Date that you will receive your high school diploma. (Month / Year)
10. High school from which you will receive your high school diploma:
11. Cumulative High School GPA (Unweighted) Class Rank out of
Section D: Student Status
12. Do you currently have a full or part-time Job? Yes No
If so, please describe and provide information about the type of job and average
number of hours per week involved.
13. Please list the extra-curricular school-related activities in which you are or have
been involved during high school (for example, coaching, choir, sports, band
organizations, clubs) and indicate any offices held and the amount of time you
have spent involved in these activities. (Points are awarded by number of years.)
Activity Offices Held Number of Years
14. Please list and briefly describe any church and community activities in which you
have been involved currently or during high school (for example, choir, usher,
scouts, 4-H), including any offices held in connection with these activities and
indicate the amount of time you have spent involved in these activities. (Points are
awarded by number of years)
Activity Offices Held Number of Years
15. Please list any honors or awards you have received. (Academics, coach, scouting,
club awards, etc.)
Section E: Household Information
16. Parents’ name and addresses:
Mother’s Name & Address Father’s Name & Address
17. Are either or both of your parent’s active, retired or deceased firefighters?
Yes No
18. If the answer to question 17 is yes, list your firefighter parent(s) by name and state
which departments(s) your firefighter parents(s) works with, and how long has that
parent(s) worked with that department(s)
19. Your parents’ current marital status:
single married separated divorced widowed
20. Number of family members.
(Include yourself and your parents, as well as any other children or other people
who live with and are supported primarily by your parents)
Please list these family members and their relationship to you (i.e. brother,
grandmother, etc.):
21. Number of family members, who will be college students in any of the next 4
years. (Include yourself)
22. Please describe any unusual circumstances which affect your family’s finances or
any other circumstances that you want us to consider for this scholarship. (for
example, physical or mental illness or disability of yourself or a parent).
Section F: Income, Earnings, and Benefits
Student (Check only one box)
23. For the 2006 Income Tax Figures, you completed:
2006 IRS Form 1040A or 1040EZ
2006 IRS Form 1040
2006 US Income Tax return was not filed.
24. 2006 Adjusted Gross Income (AGI) (IRS Form 1040EZ, line 4, IRS Form 1040A,
line 21, IRS Form 1040, line 35)
25. Any income and/or benefits received in 2002 which are not included in the above
figure (such as interest on tax-exempt bonds)
26. If no 2006 income tax return was filed, please explain why:
27. Have you received or do you anticipate receiving other scholarships or grants to
pay for your education? Yes No
If yes, please identify these sources of income and amounts:
28. Do you anticipate applying for loans to pay for your education?
Yes No
Parents (check only one box)
29. The following 2006 US income tax figures are from:
a completed (or estimated) 2006 IRS Form 1040A or 1040EZ
a completed (or estimated) 2006 IRS Form 1040
a US income tax return was not filed
30. 2006 Adjusted Gross Income (AGI) (IRS Form 1040EZ, line 4; IRS From 1040A,
line 21; IRS Form 1040, line 35)
31. Any other income and benefits received in 2006 which are not included in the
above figures (including Social Security Benefits and Aid to Families with
Dependent Children)
32. If no 2006 income tax return was filed, please explain why
Section G: Asset Information
Students and Parents complete (Put 0 if none). Please provide the value of the
following assets owned by the applicant or parents of the applicant. If necessary,
these values may be estimated.
Student Parents
Asset Debit Asset Debit
1. Home value (A)
2. Home debt (mortgage amount) (D)
3. Cash, savings and checking accounts (A)
4. If you do not own a home, list annual rent paid on
your dwelling. (D)
5. Other real estate and investments value (Do not
include the home) (A)
6. other real estate and investment debt (Do not
include the home) (D)
7. Value of retirement plans or similar assets (A)
8. Business value (include the value of an interest in
any type of business including sole proprietorship,
partnership, corporation or entity) (If you are an
employee and do not own all or a portion of your
own business, put 0.) (A)
9. Business debt (D)
Totals
(Assets minus Debts)
NOTES: (A) = Asset (D) = Debt
We realize that many students may not own homes, real estate, or some of the other listed
assets, but if they do, please include that information along with that of the parent.
Please sign and date this form to indicate that the information you have provided is accurate and
complete to the best of your knowledge.
___________________________ _____________________
Student Signature Date
_____________________________ ______________________
Father’s Signature Date
______________________________ ______________________
Mother’s Signature Date
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