ESSEC Global BBA - Scholarship request and Financial Statement – 2016-2017
1) Identification details
Student name (Family name, First and Middle):
Permanent address:
Current Address (if different):
Phone number:
Fax number:
Email:
Parent 1’s name:
Age:
Parent 1’s occupation:
Employer:
Parent 2’s name:
Age:
Parent 2’s occupation:
Employer:
Parents’ marital status: Married
Separated/divorced*
Other
*If your parents are separated or divorced, a separate Financial Statement and their most recent tax
forms must be submitted by your noncustodial parent.
Date of separation:




Date of divorce:
Noncustodial parent name:
Noncustodial parent address:
Noncustodial parent occupation:
Has either parent remarried? Custodial parent
This form is being submitted by the: Custodial household
Employer:
Noncustodial parent
Both
Noncustodial household
2) Please describe what you consider as your main achievements showing excellence (1 page
maximum to be filled by the applying student)
3) Financial Statement
How many persons, including the applicant, are dependent on the family’s income?
Name
Relationship to the Student
Age
Which persons, including the applicant, are or will be in school or university (at ESSEC or in any other
school)?
Name
2015-2016
Name of
school or
university
2015-2016
Annual cost
of
attendance
€
€
€
2015-2016
Amount
provided by
family
€
€
€
2016-2017
Name of
school or
university
2016-2017
Annual cost
of
attendance
€
€
€
2016-2017
Amount
provided by
family
€
€
€
Please list family’s total annual income in €:
Actual 2014
Income
Estimated 2015
Income
Estimated 2016
Income
Parent 1’s gross earnings
€
€
€
Parent 2’s gross earnings
€
€
€
Other income*
€
€
€
Other income*
€
€
€
Other income*
€
€
€
TOTAL
€
€
€
Annual income taxes paid
€
€
€
*Please include interest and dividend income, business income, real estate income, pension and
retirement income, as well as any other forms of income in ‘other income’.
Documentation must be provided to verify the financial information requested above. If a national tax
return is filed you must submit it in full. Please check the type of documentation you are or will be
sending:
Tax forms
Statement from employer
Other
Is either parent self-employed or does any family member hold an interest in any business/farm?
 If so, a Business/Farm Supplement, available from our website, may be required.
 Name of business/farm:
 Parents’ position(s):
Percent owned:
Please list your parents’ total assets below, in €
Present Value Amount Owed
Family home
 Year purchased:
 Purchase price: €
Land and buildings (other than home)
 Year purchased:
 Purchase price:€
Cash/savings
Investments (stocks, bonds etc)
Business or farm
Debts owed to the family
Please explain
Trusts (please provide details, including accessibility, on page 3)
Funds set aside for retirement
Assets belonging to siblings under age 18
Other
How much money does your family owe to other people?
Reason for debt
Present Value
€
Amount Owed
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
4) Assets held by your family in other countries
List student’s assets:
Total Amount
Cash/savings
Investments
Trusts
Real estate
Source (e.g. parents’ savings,
gifts, earnings)
€
€
€
€
List average amounts of money spent each year by your family for:
Rent or mortgage
Utilities
Food
Clothing
Education
Taxes
Loan/debt payments
Savings or retirement plans
Automobile maintenance
Insurance
Entertainment
Vacations
Domestic help
For how many employees?
€
€
€
€
€
€
€
€
€
€
€
€
€
Please list your outside awards/support from government agencies below:
Name of scholarship/donor
Amount expected in 2016-2017
€
€
€
€
€
Please use the space below to explain your answers to the above questions or to give additional
information which you would like the Scholarship Committee to consider while reviewing your
application. You may also attach an additional sheet.
Signature of Parent 1:
Signature of Parent 2:
Signature of Student: