Scholarship Application Form - Calendar Year 2020

Student Information:

Student's Date of Birth:

One of the following boxes must be checked:

The student is a Georgia resident who, immediately prior to receiving a scholarship or tuition grant and enrolling in a qualified school or program, was enrolled in and attended for at least six weeks a Georgia secondary or primary public school or who is eligible to enroll in a qualified first grade, kindergarten program, or pre-kindergarten program.
The enrollment and six-week public school attendance requirements shall be waived in the case of a student who: • based on the school attendance zone of his or her primary residence, is or would be assigned to a public school that the Office of Student Achievement determines to be a low-performing school,    • who is the subject of officially documented cases of school based physical violence or student related verbal abuse threatening physical harm,    • who was enrolled in a home study program for at least one year immediately prior to receiving a scholarship or tuition grant.
The student has previously been eligible for the program.

Parent Information:

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Select the button for your 2019 Adjusted Gross Income (for audit reporting purposes only):

# in Household Below Between Between Above
1 $15,950 $31,900 $51,040
2 $21,550 $43,100 $68,960
3 $27,150 $54,300 $86,880
4 $32,750 $65,500 $104,800
5 $38,350 $76,700 $122,720
6 $43,950 $87,900 $140,640
7 $49,550 $99,100 $158,560
8 $55,150 $110,300 $176,480

I hereby certify that the information contained herein is true and accurate to the best of my knowledge. I hereby authorize Georgia SSO to release the information provided above to the listed school.

Type your name as evidence of signature *

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