StarTalk Vermont Student Program 2015
A Scholarship Application Form
Thank you for your interest in applying to the StarTalk Vermont Student Program 2015.
Use this form to request a scholarship. The following is the guideline.
Are you eligible to apply? If your family’s house income is less than $44,000 per year you
qualify to apply for financial scholarship assistance (provided we get all of your financial
information in time.) Even with a higher income, you may qualify if your family has multiple
children or households, unexpected loss of income, flood or hurricane damage, or other
extenuating circumstances. In a written letter, please tell us why you are requesting scholarship
assistance. Please include a copy of the bill for flood/hurricane damage or other helpful
information.
HOW TO APPLY:
 Print and complete this application form: Be sure to complete all fields. Make sure a
parent or guardian competes his or her portion of the application and sign it. (Incomplete
applications may make you ineligible for financial aid.)
 A copy of the first page of most recent federal tax: If parents are filing separately, we
need documentation from each parent. We cannot consider applications without fields
filled in or without the tax information.
 A request letter: If your family’s income is greater than $44,000 per year, write a letter
explaining why you are requested financial scholarship. If your family has extenuating
circumstances, please write your reason for the request. A single page document is
sufficient.
All families are expected to contribute as much as they can. The StarTalk Vermont Student
Program’s Scholarship funds are limited. Ask only for what you need in order to ensure enough
resources are available to everyone who needs financial support.
Please make sure to mail your completed an application package to the following address with
your StarTalk Student program application:
StarTalk Vermont Student Program 2015
The University of Vermont
Mann Hall Room 201
208 Colchester Avenue
Burlington, VT 05405
For any questions, please contact Jacqueline at Jdrouin@uvm.edu or call 802-656-8576.
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Complete this form ONLY if you are applying for a scholarship assistance
StarTalk Vermont Student Program 2015
Scholarship Application
Student Name: ___________________________________
School: ________________________
Student Resources:
2014 income from wages, salaries, tips, etc.
$________________
2014 unearned income (gifts, social security benefits, etc.)
$________________
Current value of student’s savings and investments
$________________
Value of trust fund of which student is beneficiary
$________________
Year, make and model of student’s car ____________________________________________
Parent Resources:
2014 adjusted gross income (bottom of 1st page of federal tax return)
$________________
Father’s 2014 wages
$_________________
Mother’s 2014 wages
$_________________
2014 nontaxable income : $_________________ (child support, pension plan, unemployment
compensation, etc.)
Household: Own home / Rent (please circle)
Amount your family can pay in tuition?
$________________
Amount of scholarship you are requesting?
$_________________
Your signature below certifies that the information you have provided is accurate and that you
understand, acknowledge, and agree with the following disclosures and requirements:
StarTalk Vermont will hold our information confidential. You have our consent to use it
to administer the Scholarship Program, including reports requested by the sponsor and
publications that include non-identifying information.
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I, the student applicant, understand that it is my responsibility to mail this application in
time to meet the deadline of June 1, 2015. I understand that if it is received after this
date, it may disqualify me to receive financial aid. I understand financial assistance is
awarded on a first-ask, first-serve basis.
If I receive a scholarship award, it will be my responsibility to a) accept the award by the
deadline provided or forfeit the award, and b) pay our family’s portion of fees at the
required time unless I make other arrangements.
Student Applicant Signature: ______________________________ Date:_________________
Parent/Guardian Signature: _______________________________ Date: _________________
PRINT Parent/Guardian Name: ____________________________
Please confirm the email address and phone number at which StarTalk Vermont staff can best
communicate with you:
Email Address: ________________________________________________________
Phone Number: ________________________________________________________
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