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UNITEDlrtAYOFBUTLER
COUNTY
APPLICATION
FORPRE-K
EITCSCHOTARSHIP
To gualifufor this scholarchip,the Farentsof the student must either reride or be employedby a company
locatedin Arnrstront or Butler Counties.An eligibfestudent is a Pre-Kagestudent (three to six yearcof agel who
is a residentof Pennsylvania,
enrolledin a Pre-KProgramlocated in this Commonweahh,and a memberof a
householdwi$r an annualhouseholdincomeof not morethan $76,350,exceptthatan additionalincome
allowanceof $15,270is permitted for the student and for eachother dependent(asdefined by the lRSltiving
within the samehousehold.
1. Complete this application and return to the addressbelow by June t7,20t6. NO APPLICJITIOIIIS
POSTMARKED
AFTERru|s DATEWIIL BECONSIDERED
FORTHE2015-20T6SCHOOLYEAR.
2. Attach the following to the completed application:One (U copy of the Family}OLSFederalIncome
Tax Return(Form 1040),pages1 and 2 only of the personthat claimsthe childrenapplyingfor a
schofarship.lf no taxes were filed, you must provide proof of whatever income you have (SSl,Child
Support,FoodStamps,etc.).
3. Sendthe completed applicationto the United Way of Butler County,184 PittsburghRoad,Butler,
16001.
Pennsylvania
Name of Parent(s)

HomeAddress
City

Zip

State

PhoneNumber(s)
EmailAddress(do not list if you don't checkregularly)
(pleasecheckone):fl ArmstrongflButler[
Countyof residence

*Other

*lf you do not residein Armstrongor ButlerCounties,

pleaseprovidethe following;
Placeof Employment:

Companyaddress:
Countyof employment(pleasecheckone): fl Armstrongfl Butler
Pleaseprovideinformationfor eachdependentchildapplyingfor a scholarship:
Name
Name
Pre-KAge:
Schoolenrolled at

TuitionCost{annual}

Pre-KAge:
Schoolenrolledat
TuitionCost(annuall

Pre-KAge:
Schoolenrolledat
TuitionCost(annual)

Schoolenrolledat
TuitionCost(annual)

phase provi6earryinformationconcerningchangesin your financialstatussincethe abovereturn was

filed on a separatesheetof paper(anyexplanationof reducedincomeMUSI be accompaniedby
supportlrg docurrentatbn to be considered).

To the bestof my knowledge,all of the informationaboveand attachedis accurateand true.

Signatureof ParentlGuardian

All infqrnation h kept confi&ntial.