Parent Guardian Financial Statement

Step 1 of 2

Complete and submit the form online or download blank forms. DO NOT staple or permanently bind any of your application materials in any way. If Mailing, PLEASE SEND ALL INFORMATION TO THE HORACE SMITH FUND AT THIS ADDRESS: THE HORACE SMITH FUND 16 Union Avenue, Ste. 2-K Westfield, MA 01085

This form is used to determine financial need for students who are currently in college. If applicant is an independent or non-traditional student, please complete the form based on own finances. High school seniors who are about to enter college must complete the CSS Profile application found at cssprofile.collegeboard.org.

PERSONAL DATA

Name of Student(Required)

First Middle Name or Initial Last

Name of Parents or Guardians(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

PERSONAL FINANCES

Father’s Employer

Father’s Position

Employer’s Address

Street Address Address Line 2 City State ZIP Code

Father’s annual salary or gross income from business or profession

Mother’s Employer

Mother’s Position

Employer’s Address

Street Address Address Line 2 City State ZIP Code

Mother’s annual salary or gross income from business or profession

Gross income from other sources

Gross income provided by other family members

Total Annual Family Income

List and explain any recent unusual or unexpected expenses or income.

List other family members who are either financially dependent or who contribute to the family’s support.

Name

Age

School or Place of Employment

Dependent?

Dependent

Contributes

Name

Age

School or Place of Employment

Dependent?

Dependent

Contributes

Name

Age

School or Place of Employment

Dependent?

Dependent

Contributes

Name

Age

School or Place of Employment

Dependent?

Dependent

Contributes

CASH (include bank and money market accounts, CD’s)

Marketable securities (stock, bond, mutual funds)

Market value of real estate

Other assets (include autos, etc.)

Retirement funds (IRA’s, 401k, annuities)

Total Assets

Real estate mortgage debt

Secured loans (autos, RV’s, boats, etc.)

Unsecured loans (credit card debt, etc.)

Other liabilities

Total liabilities

Amount of annual rent for your family resident, if any.

Amount you intend to contribute to applicant’s education next year.

Write any additional information or comments

Signature of Parents/Guardians:(Required)

Hidden

Date(Required)

Signature of Parents/Guardians:(Required)

Hidden

Date(Required)

PERSONAL DATA

PERSONAL FINANCES

Contact

News

Give