2013 LILLY ENDOWMENT
COMMUNITY SCHOLARSHIP
Administered by: Heritage Fund – the Community Foundation of Bartholomew County
The Scholarship Selection Committee will consider the following criteria:
- Academic Performance
- School Involvement
- Financial Situation (EFC)
- Community Involvement
- Student Answered Questions/Short Essay
- Other (i.e., work, first-generation college, special circumstances)
Eligibility Requirements:
A resident of Bartholomew County, Indiana, and have graduated with a diploma from a public or private
Indiana high school (accredited by the Indiana Department of Education) by the end of June 2013, but not
have graduated before the start of the 2012-2013 school year. Students graduating mid-year are eligible.
Have at least 9.0 GPA on a 12.0 point system or a 3.33 GPA on a 4.0 point system at the end of the sixth
semester of high school. (An official high school transcript is required.)
Able to demonstrate school involvement, community service, good character and leadership skills.
Have been accepted to pursue a full-time baccalaureate course of study beginning in the fall of 2013 at an
accredited public or private college or university in the state of Indiana. (The recipient must notify the
Heritage Fund prior to May 1, 2013, which Indiana college he/she will attend.)
Be available for a personal interview with the selection committee, if chosen as a finalist.
About the Lilly Endowment Community Scholarship:
The purpose of the Lilly Endowment Community Scholarship Program is to help raise the level of educational
attainment in Indiana and to increase the ability of Indiana community foundations to enhance the quality of life for
the state’s residents.
Since the Scholarship Program began in 1998, 33 Bartholomew County students have been named Lilly
Endowment Community Scholars. The Endowment has awarded more than $1,948,552 collectively to these
scholars.
These scholarships provide full tuition, required fees and a special allocation of up to $900 per year for required
books and equipment for four years of undergraduate study on a full-time basis, leading to a baccalaureate degree at
any Indiana public or private college or university accredited by the North Central Association of Colleges and
Schools. The scholarship does not cover room and board expenses.
The Lilly Endowment Community Scholarships are administered by Heritage Fund and the Independent Colleges
of Indiana. Up to two Lilly Scholarships may be awarded to Bartholomew County students in 2013.
Scholarship recipients will be notified of the award no later than March 30, 2013.
SUBMIT APPLICATION TO:
HERITAGE FUND, P.O. BOX 1547, COLUMBUS, IN 47202-1547
812-376-7772 • E-mail: calspaugh@heritagefundbc.org • Web site: www.heritagefundbc.org
APPLICATION DEADLINE: DECEMBER 7, 2012, 4:00 P.M.
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2013 Lilly Endowment Community Scholarship – Bartholomew County
Application Procedure:
The following check-off list will assist you in completing the application. A completed application includes:
Completed application including financial information
Student answered questions and short essay (space provided in application, extra sheets
will not be accepted)
Two recommendation forms (more than two will not be accepted)
Official high school transcript
NOTE: IT IS THE APPLICANT’S RESPONSIBILITY TO PROVIDE ALL THE REQUIRED
DOCUMENTS TO THE HERITAGE FUND OFFICE ON OR BEFORE THE DEADLINE.
APPLICATIONS SUBMITTED WITHOUT ALL THE REQUIRED FORMS WILL NOT BE CONSIDERED.
ADDITIONAL DOCUMENTS AND/OR RESUMES WILL NOT BE ACCEPTED.
Financial Form:
A completed financial form (included with the application) is a requirement for this scholarship.
Please use 2011 Federal tax information to complete this form.
Short Answer Questions and Essay:
The application includes three short answer questions and a one-page essay. Space for the short answer questions
and essay are included in the application. The essay may not be longer than one page (single side) typed in
not less than 10-point font and double-spaced. Any additional pages will not be accepted.
Recommendation Forms:
Two recommendation forms must be submitted with your application. One form is to be completed by a classroom
teacher you have had during your four years of high school. The second recommendation is to be completed by a
counselor, advisor, supervisor or other professional with whom you have had a working relationship. Neither
recommender can be related to the applicant in any way. Recommenders should use only the form provided.
Additional pages will not be accepted. Information provided on the recommendation forms must be typewritten in no smaller than a 10 pt. typeface or legibly handwritten in black ink. It is also acceptable to cut and paste
a Word document if you desire; however, the recommendation must fit in the space provided (one page-one
sided).
Official Transcript:
An official high school transcript reflecting the applicant’s sixth semester grade point average, class rank and
standardized test scores is to be included with this application (either electronically by Docufide or printed and
placed in a sealed envelope by the high school). Please make sure that all the required information is included on the
transcript.
All information will remain strictly confidential.
APPLICATION DEADLINE: DECEMBER 7, 2012, 4:00 P.M.
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2013 LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION
This application must be submitted along with all other documents required for the application process. Do not submit information on other
forms/papers …answer all questions on this form only. Please type or write legibly. Please fill out the form completely. If an area on the form does not
apply to you, please note “not applicable or N/A”. Application must be type-written or filled out with black ink only. Pencil
and other color ink will not be accepted.
PART I:
Student’s Full Name:
Nickname:
Date of Birth:
Residing Address:
County:
Mailing Address (If different than above):
Home Phone:
Student’s Cell Phone:
Student’s Email Address:
Parent’s Email Address:
Name of Parents/Guardians
Relationship to Student:
Daytime Phone:
Student Commitment:
 If I receive this scholarship, it is my intent to pursue four years of undergraduate study on a full-time basis
leading to a baccalaureate degree at an Indiana college.
I
understand
that the total amount of my scholarship is calculated on the basis of my chosen college’s tuition

and required fees beginning with the 2013-2014 school year.
 To assist with the processing of my scholarship payments each semester or quarter and to avoid late fees, I
will forward to Heritage Fund immediately upon receipt all invoices received for tuition and any eligible
fees that may be covered by my scholarship.
 I will account for and return to Independent Colleges of Indiana any amount of the special allocation for
required books and required equipment remaining at the end of each school year.
 I agree to notify Independent Colleges of Indiana of any scholarship awards I may receive for tuition or
required fees from a source other than the Lilly Endowment Community Scholarship.
I
will
keep Heritage Fund apprised annually by June 1st of my enrollment and academic status during college,

by completing and returning any survey forms provided by the community foundation.
 Upon graduation, I will keep Heritage Fund apprised annually by June 1st of my education and/or
employment status for at least ten years after graduation, by completing and returning an alumni
survey or other forms as may be provided by the community foundation.
I hereby affirm that the information provided on this document is accurate and complete to the best of my
knowledge. I understand that falsification of any information may result in the termination of any scholarship
awarded. I give my consent for it to be shared with the Heritage Fund Scholarship Committee and its Board of
Directors, Lilly Endowment Community Scholars Program Selection Committee and Independent Colleges of
Indiana (ICI). Heritage Fund has my permission to use my photograph and any general, non-financial information
included in this application for publicity purposes. I agree to comply with the statements listed above.
Student Signature:
Date:
Printed Student Name:
Parent/Guardian Signature:
Date:
Printed Name:
APPLICATION DEADLINE: DECEMBER 7, 2012, 4:00 P.M.
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Part II
High School You Attend:
MALE
High School City/State:
GPA:
High School Graduation Date:
Class Rank:
SAT Scores
Math:
FEMALE
Out of:
ACT Composite Score:
Critical Reading:
Total of Math and Critical Reading:
Are you the first generation among your family members to attend college?
YES
NO
Are you a member of the 21st Century Scholarship Program?
YES
NO
How long have you lived in Bartholomew County?
Name of university or college you plan to attend, in order of preference:
Name of School
4-year Tuition
Applied?
1st
Status
$
YES
NO
Accepted
Unknown
2
nd
$
YES
NO
Accepted
Unknown
3
rd
$
YES
NO
Accepted
Unknown
Intended Major(s):
Minor(s):
List your 5 most important scholastic honors or awards from high school.
Name of Honor/Award
Group Issuing Honor/Award
Year Awarded (9, 10, 11, 12)
List your 10 most important school activities and/or organizations, year(s) in which you are now or have been an
active participant (in no particular order), and the weekly hours you have committed to that activity by year in
school. Identify any in which you’ve held a leadership position.
Activity/Organization
9
10
11
12
Name of Leadership Position
Example::
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- Band/Orchestra
- Student Council
10 hrs
10
10
1
10
1.5
Secretary (11, 12)
V.P. (11); Pres (12)
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List any community involvement or volunteerism in which you are now or have been an active participant (in no
particular order), and the weekly hours you have committed to that activity by year in school. Identify any in which
you’ve held a leadership position.
Community Involvement/Volunteerism
Example:: - Turning Point
9
10
11
12
-
2
2.5
3
Name of Leadership Position
Dance Marathon Committee (11, 12)
Please list any scholarships for tuition, required fees or books you expect to receive or have applied for.
# of
Total
Status: (Unknown,
Name of Scholarship
Awarding Institution
Years
Amount
Approved)
$
$
$
$
How do you plan to finance your education? (100 words max.)
Work History:
Position Held
Employer
From:
Mo./Yr.
To:
Mo./Yr.
Avg.
Hrs./Wk.
Approx. Total
Amount
Earned
$
$
$
$
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Part III – Financial
PLEASE READ AND FOLLOW ALL DIRECTIONS CAREFULLY




Submitting a completed financial form is a requirement for this scholarship. All information will remain strictly
confidential. If a question does not apply, please indicate with N/A. Do not leave any space blank.
Use information from your 2011, not your 2012, tax returns. (Financial information is requested from your 2011 tax
returns because most people will not have their 2012 taxes finished by the December 7th scholarship deadline.)
If you feel you have special circumstances that significantly impact your finances that will not be reflected in this
form, please contact the Scholarship Manager at Heritage Fund at (812) 376-7772.
If selected as a finalist, you may be asked to provide supporting documentation.
Parents’/Guardians’ current marital status (check one):
Mother:
Married/Remarried
Occupation/Title:
Father:
Married/Remarried
Occupation/Title:
Divorced
Separated
Employer:
Divorced
Widowed
Deceased
Length of Employment:
Separated
Employer:
Highest education completed:
Mother:
Unknown
Middle School/Jr. High
Some College/Associate’s Degree
Father:
Single
Unknown
Middle School/Jr. High
Some College/Associate’s Degree
Single
Widowed
Deceased
Length of Employment:
High School
Technical/Vocational School
Bachelor’s Degree of Higher
High School
Technical/Vocational School
Bachelor’s Degree of Higher
If your parents are divorced or separated, please indicate each parent’s monetary contribution to your education.
Father’s Contribution:
$
Mother’s Contribution: $
Number in household (include yourself, siblings, parents):
Number of household members who will be enrolled at an accredited post-secondary institution (at
least six hours) for the 2013-2014 academic year. Include the Lilly applicant and any siblings/stepsiblings. Do not include parents.
Custodial parents’/guardians’ state of legal residence:
Number
Age of older parent:
Please explain any special family, personal or financial situations that the Selection Committee should know about in
reviewing your scholarship needs. (150 words max.)
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Part III – Financial continued
If you are a Dependent student, please have your parents/guardians complete the PARENT section of this form.
You must complete the STUDENT section.
To claim independent status, you must (1) have served in the military, (2) be a ward of the courts, (3) be married
and living away from your parents, (4) be an emancipated minor, or (5) have not been claimed by your
parents/guardians for two consecutive years and have earned at least $4,000 in each of those two years. Circle all of
the above conditions that apply (documentation may be required). If none of these conditions apply, the
STUDENT and PARENT sections must be completed.
Student
• Did you file a 2011 income tax return?
Parent(s)
YES
NO
YES
NO
• If you filed a 1040, were you eligible to file a 1040A or 1040EZ?
YES
• 2011 Adjusted Gross Income (1040-Line 37, 1040A-Line 21 or 1040EZLine 4)
$
• 2011 U.S. Income Tax Paid (1040-Line 71, 1040A-Line 44 or 1040EZLine 10)
$
NO
YES
NO
$
$
Answer these questions whether or not you filed 2010 tax returns.
• 2011 Student’s income earned from work:
$
• 2011 Father/guardian income earned from work:
$
• 2011 Mother/guardian income earned from work:
• Total of: Earned income credit, additional child tax credit, welfare
benefits including Temporary Assistance for Needy Families and untaxed
Social Security benefits:
• Total of: Contributions to tax-deferred pension and savings plans, tax
exempt interest income, any other untaxed income or benefits not
reported elsewhere (IRA payments, worker’s compensation, etc.):
• Total of: Child support paid, education credits, taxable earnings from
Federal Work Study, student grants and scholarships included in Adjusted
Gross Income:
$
$
$
$
$
$
$
$
$
$
$
$
$
Asset Information (all values as of September 28, 2012)
• Cash, savings and checking accounts:
• Net worth of investments value** (net worth = current value minus
debt):
• Net worth of current businesses/investment farms*** (net worth =
current value minus debt):
** Investments include real estate, trust funds, money market funds, mutual funds, certificates of deposit, stocks, stock options, bonds,
other securities, educational IRAs, college savings plans, installment and land sale contracts (including mortgages held), commodities, etc.
Exclude the home you live in, life insurance and retirement plans (i.e., 401k, 403b, Keogh Plan).
*** Businesses and/or investment farm value includes the market value of land, buildings, machinery, equipment, inventory, etc. Debt
includes only those debts for which business or farm was used as collateral. Do not include a farm that you live on and operate.
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Part IV – Short Answer Questions
Question 1: Describe how you have been influenced by an individual or an event and how you believe it will shape
your future. (200 words max.)
Question 2: Where do you see yourself in 10 years? (200 words max.)
Question 3: Why should the Selection Committee select you to receive a scholarship? (200 words max.)
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2013 LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION
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Part V – Essay (enter content below, 1-page, double spaced)
There are many local, national, and world issues affecting us today. What issue is a major concern for you and why?
Explain what skills and resources you have or hope to develop that would make a difference. (450 words max.)
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2013 Lilly Endowment Community Scholarship – Bartholomew County
2013 LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION



Applications submitted without all the required and completed forms will not be considered.
Completed applications should be turned-in/mailed to Heritage Fund in an envelope marked “2013 Lilly
Scholarship.”
Please do not staple any pages of the application (paper clips are acceptable).
Return completed forms to:
Heritage Fund - the Community Foundation of Bartholomew County
538 Franklin Street, P.O. Box 1547, Columbus, IN 47202-1547
APPLICATION DEADLINE: DECEMBER 7, 2012, 4 P.M.
About Heritage Fund:
Heritage Fund - the Community Foundation of Bartholomew County was created in December 1976 as the final act
of the Columbus/Bartholomew County Bicentennial Corporation. As a community foundation, Heritage Fund is a
vehicle designed to serve philanthropic donors who want to help improve their community.
The concept of a community foundation is to build substantial endowment funds which are permanently invested
to produce income. The earned income is then re-invested into the community. For the year ending 12/31/11 the
foundation disbursed more than $3.9 million in grants and scholarships to not-for-profit organizations and students.
Like most community foundations, Heritage Fund does not provide direct services but instead awards grants to
charities and organizations in our community that best carry out donors’ interests and meet community needs.
Since most of the assets are permanently endowed, Heritage Fund will be able to help meet the community’s
charitable needs forever.
About Lilly Endowment:
Lilly Endowment Inc. is an Indianapolis-based, private philanthropic foundation created in 1937 by three members
of the Lilly family - J.K. Lilly, Sr., and sons, J.K., Jr. and Eli - through gifts of stock in their pharmaceutical business
Eli Lilly and Company.
These gifts remain the financial bedrock of the endowment. Lilly Endowment is, however, a separate entity from
the company, with a distinct governing board, staff and location. In keeping with the wishes of its three founders,
Lilly Endowment exists to support the causes of religion, education and community development. Special emphasis
is afforded projects that benefit youth and the leadership, education and financial self-sufficiency of the nonprofit,
charitable sector. One of the Lilly family’s foremost philanthropic priorities was to help the people of their city and
state build a better life. Although the Endowment supports efforts of national significance and an occasional
international project, it remains primarily committed to its hometown, Indianapolis, and home state, Indiana.
OUR MISSION
Heritage Fund is a community foundation created primarily for Bartholomew County to:
 Provide responsible stewardship of gifts donated for broad charitable purposes;
 Promote leadership to address community issues;
 Serve as a catalyst for positive change in partnership with others; and
 Promote philanthropy broadly within the community.
“It is the general policy of Heritage Fund – the Community Foundation of Bartholomew County to include people without
regard to age, disability, economic circumstances, ethnicity, gender, race, religion or sexual orientation in carrying
out our mission.” Adopted by the Heritage Fund Board, May 4, 2003
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Part VI – Classroom Teacher Recommendation Form
Please do not refer to the applicant by name anywhere on this form. The applicant’s first and last name must
be included on the outside of a sealed envelope or on a separate, securely attached sheet.
Return this form in a sealed envelope by November 30, 2012 to the student; or by 4 p.m., December 7, 2012, to the
Heritage Fund, P.O. Box 1547, Columbus, IN 47202-1547. Failure to meet these deadlines will jeopardize the
applicant’s opportunity to be considered for this scholarship.
The information must be typed in no smaller than a 10-point font or legibly hand-written in black ink. It is
acceptable to cut and paste a Word document if desired. However, the recommendation must fit in the space
below only. Additional materials should not be included and will not be considered.
Relationship to Applicant:
How well have you known the applicant?
Period of time you have known the Applicant:
Very Well
Fairly Well
Limited Contact
Please rate the Applicant in the following categories with comments explaining the rating:
Top 1% = 9-10 pts.; Top 10% = 7-8 pts.; Top 20% = 5-6 pts.; Average = 3-4 pts.; Below Average = 1-2 pts.
1-10 Rating
Comments (25 words per line max.)
Self-Concept
Ability to set realistic goals
Cooperation
Work Habits
Integrity/Honesty
Perseverance
Responsible
Respectful
In your opinion, what distinguishes this student from his/her peers? (200 words max.)
Form completed by:
Title:
Signature:
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Phone:
E-mail:
Date:
2013 Lilly Endowment Community Scholarship – Bartholomew County
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Part VII – Recommendation Form for Counselor, Advisor, Supervisor or other Professional
Please do not refer to the applicant by name anywhere on this form. The applicant’s first and last name must
be included on the outside of a sealed envelope or on a separate, securely attached sheet.
Return this form in a sealed envelope by November 30, 2012 to the student; or by 4 p.m., December 7, 2012, to the
Heritage Fund, P.O. Box 1547, Columbus, IN 47202-1547. Failure to meet these deadlines will jeopardize the
applicant’s opportunity to be considered for this scholarship.
The information must be typed in no smaller than a 10-point font or legibly hand-written in black ink. It is
acceptable to cut and paste a Word document if desired. However, the recommendation must fit in the space
below only. Additional materials should not be included and will not be considered.
Relationship to Applicant:
How well have you known the applicant?
Period of time you have known the Applicant:
Very Well
Fairly Well
Limited Contact
Please rate the Applicant in the following categories with comments explaining the rating:
Top 1% = 9-10 pts.; Top 10% = 7-8 pts.; Top 20% = 5-6 pts.; Average = 3-4 pts.; Below Average = 1-2 pts.
1-10 Rating
Comments (25 words per line max.)
Self-Concept
Ability to set realistic goals
Cooperation
Work Habits
Integrity/Honesty
Perseverance
Responsible
Respectful
In your opinion, what distinguishes this student from his/her peers? (200 words max.)
Form completed by:
Title:
Signature:
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Phone:
E-mail:
Date:
2013 Lilly Endowment Community Scholarship – Bartholomew County
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2013 Lilly Endowment Community Scholarship – Bartholomew County