St. Mary School of Blessed Trinity Parish
105 East Main Street, P.O. Box 39
Brussels, Illinois 620013
School Year: 2012 - 2013
Application Due Date: July 2, 2012
TUITION ASSISTANCE IS AVAILABLE ONLY TO ACTIVE, PRACTICING,
REGISTERED MEMBERS OF BLESSED TRINITY PARISH.
Dear Parent/Guardian,
We appreciate every family’s sacrifice to send their child to St. Mary School. This application is designed to
get the clearest and most accurate understanding of your family’s current financial situation.
In order for the Tuition Assistance Review Committee to fully understand each family’s unique
circumstances and requests for tuition assistance, it is important that you complete the Tuition Assistance
Application Form in its entirety and submit it, along with a copy of your 2011 personal income tax return, to the St.
Mary School office at the address provided above by the due date listed at the top of this letter.
PLEASE NOTE: Your request cannot be considered or processed without complete documentation.
Please know that all information will be kept strictly confidential. It will not be with your child’s school
records. It will only be used by members of the Tuition Assistance Review Committee to determine your eligibility
to receive financial assistance. This information is needed in order to insure that any and all assistance is
distributed in an equitable manner.
Assistance is awarded annually and only for the current school year. You will need to reapply each year, if
needed.
St. Mary School of Blessed Trinity Parish
105 East Main Street, P.O. Box 39
Brussels, Illinois 620013
TUITION ASSISTANCE APPLICATION FORM
FAMILY/HOUSEHOLD INFORMATION
Parents/Guardians Name(s) __________________________________________________________________________________________________
Address _________________________________________________________________________________________________________________________
Telephone (home/cell) ____________________________________________________ ______ (work/business) _________________________
Name & ages of all children in the household ________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Children in College _____________________ Tuition Payment $___________________ Scholarship/Aide/Grants $______________
Parish/Church Affiliation ______________________________________________________________________________________________________
EMPLOYMENT/INCOME INFORMATION
Father ___________________________________________ Position ______________________________________ Annual Rate $______________
Mother __________________________________________ Position ______________________________________ Annual Rate $______________
If you are a single parent (divorced or separated) does the other parent pay child support? Yes ________ No ________
If yes, how much support is paid per month? $ ____________________
ASSISTANCE REQUEST
1. Are there any changes to the # of dependents claimed on the attached tax return? Yes ____________ No ____________
If yes, please explain ________________________________________________________________________________________________________
2. Are there any changes to the income claimed on the attached tax return? Yes __________________ No ________________
If yes, please explain. _______________________________________________________________________________________________________
3. Please explain below any additional circumstances/facts which should be taken into consideration when
evaluating your request for tuition assistance. Please be as specific as possible.
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
4. Please prayerfully consider your family’s financial situation and creatively think through ways to minimize
other expenses and bring other income into your home in order to pay tuition. After examining all these factors,
what is the maximum amount of tuition you believe you can pay?
Tuition we can pay monthly $_______________________________________
SMS CANNOT OFFER 100% ASSISTANCE – EACH FAMILY MUST MAKE A FINANCIAL CONTRIBUTION.
I (We) certify that all information on this application is true and all income is reported.
___________________________________________________________________________________
___________________________________________
_
__________________________________________________________________________________
___________________________________________
Parent/Guardian Signature
Parent/Guardian Signature
Date
Date