Scholarship Application Form - Calendar Year 2019

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:

Select the button for your 2018 Adjusted Gross Income (for audit reporting purposes only):

# in Household Below Between Between Above
1 $15,175 $30,350 $48,560
2 $20,575 $41,150 $65,840
3 $25,975 $51,950 $83,120
4 $31,375 $62,750 $100,400
5 $36,775 $73,550 $117,680
6 $42,175 $84,350 $134,960
7 $47,575 $95,150 $152,240
8 $52,975 $105,950 $169,520

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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