UAA Spouse Tuition Scholarship
Applicant's Data
1. NAME (Last, First, MI)
2. SSN
STUDENT NUMBER
3. MAILING ADDRESS:
4. HOME PHONE
5. WORK PHONE
Sponsor's Data
6. NAME (Last, First, MI) RANK
7. SSN
8. UNIT & UNIT MAILING ADDRESS:
9. DEROS
10. DUTY PHONE
Educational Data
11. DEGREE LEVEL (“X” BLOCK THAT APPLIES)
Certificate
Associate
Bachelor
Graduate
13. HOURS REQUIRED FOR DEGREE:
12. DEGREE PROGRAM / MAJOR
14. HOURS COMPLETED TOWARD DEGREE:
15. COURSES THIS TERM: Please refer to Item 15 Instructions NO DUPLICATE COURSES (all fields must be filled out for each class listed)
Example: Course – MATH 101 Course Title – General Math (MATH 101(DE) when class is distance education (on line)
Course
Course Title
# of Credit Hours
Tuition cost per class Class Start
Date
16. TOTAL TUITION FOR ALL CLASSES: $
17. HAS ANY GRADE BEEN LESS THAN “C” (“B” FOR GRADUATE)? (
IF YES HAS STAP BEEN REPAID? ( YES/
NO)
18. HAVE YOU APPLIED FOR ANY OTHER AID?
( YES/
NO)
IF YES, WHAT IS IT?
YES/
NO)
19. DID YOU QUALIFY? ( YES/
NO); IF YES, HOW
MUCH/ PER TERM FOR TUITION ONLY:
Financial Data: An end-of-month LES dated within the last 60 days must be attached with application
20. SPONSORS MONTHLY
BASE PAY:
21. ½ OF SPONSOR’S
MONTHLY OUTSIDE
GROSS INCOME (Example:
Part-time job, etc.)
22. ½ of APPLICANTS MONTHLY
GROSS INCOME (attach pay stub)
$
$
$
24. DO YOU OWE ANY OUTSTANDING LOANS TO AFAS (EA OR STAP)?
Explain:
(
YES/
23. NUMBER OF DEPENDENT
CHILDREN
NO)
Base Remarks
I understand the Scholarship will only pay for classes listed above. It is my responsibility to notify UAA of any class changes made prior to the
“final add/drop date”. Spouse Tuition Assistance will not be provided for changes made to your class schedule after the “add/drop” date has
passed.
____________________
______________________________________________
Applicant Initials
Committee Approval
25. Student’s Signature
Date
26. Sponsor’s Signature Date