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Scholarship Intent From 23-24

This document is a form for parents to provide information needed to apply for an Indiana Choice Scholarship voucher for the 2023-2024 school year. It requests the names and grades of students, home address, contact information, income documentation, and requires parents to confirm they understand the eligibility requirements. Parents must select which eligibility track their student qualifies under and verify the accuracy of the household size and income being reported.

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Josh Knoedler
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52 views2 pages

Scholarship Intent From 23-24

This document is a form for parents to provide information needed to apply for an Indiana Choice Scholarship voucher for the 2023-2024 school year. It requests the names and grades of students, home address, contact information, income documentation, and requires parents to confirm they understand the eligibility requirements. Parents must select which eligibility track their student qualifies under and verify the accuracy of the household size and income being reported.

Uploaded by

Josh Knoedler
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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2023-2024 IDOE CHOICE VOUCHER FORM

*This is an in-house CCS form used to gather the necessary information to file for a choice voucher.

Parent/Guardian Name(s): ________________________________________________________________________

Student(s) Information:
_____________________________________________________________________________________________
Last Name First Middle Grade (fall 2023) DOB

_____________________________________________________________________________________________
Last Name First Middle Grade (fall 2023) DOB

_____________________________________________________________________________________________
Last Name First Middle Grade (fall 2023) DOB

_____________________________________________________________________________________________
Last Name First Middle Grade (fall 2023) DOB

_____________________________________________________________________________________________
Last Name First Middle Grade (fall 2023) DOB

Student(s) Home Address:

_____________________________________________________________________________________________
Street City State Zip Code

County of Residence: __________________________________________

Parent Phone Number: (____) - _____ - ______ Parent E-mail address: __________________________________

List any student(s) that have an Individualized Education Program (IEP)/Service plan: ________________________
_______________________________________________________________________________________________

Indicate which Track (pathway) your student(s) will use to qualify for the scholarship this year.

(initial) - I have read the Choice Scholarship Program Track Eligibility Requirements 2023-2024 document
for Track descriptions & requirements.

Choose ALL that apply:


___ Previous Choice Scholarship Student Track (student received voucher in any prior year)
___ Previous SGO Award Track (student received SGO in any prior year)
___ Special Education Track
___ “F” Public School Track
___ Two-Semesters in a Public School Track
___ Sibling Track (sibling had a voucher or SGO in a prior school year)
___ Foster Track (Need letter dated in 2021 from DCS case worker)
Reference the Choice Scholarship Program Income Limits by Household Size 2023-2024 document as well as the
Choice Scholarship Program Income Verification Rules 2023-2024 document that explains how the Household Size
and Household Income are determined for Choice Scholarship Purposes.

Household size at the time of application:

Household income from 2022:


Type of Income (extra lines provided for income not included in AGI) Amount of Income
Adjusted Gross Income (AGI) from 2022 Federal tax return $
$
$
$
$

Total 2022 Household Income (Required) $

Proof of total income must be accurate and submitted for EACH household member (if contained on separate 1040s).

VERIFYING HOUSEHOLD SIZE & INCOME

(initial) – I have read the Choice Scholarship Program Income Limits by Household Size 23-24 document
(initial) - I have read the Choice Scholarship Program Income Verification Rules 23-24 document

If a 2022 Federal Tax Return is available and provides a current & accurate picture of household size and income, the
Adjusted Gross Income amount on the Federal Tax Return should be used to determine income eligibility.
• If members of the same household filed separate 2022 Federal Tax Returns, the Adjusted Gross Income and
household sizes for each return should be added together to determine the total household income and size and
complete the Household Summary Form. If separate Tax Returns are being used, please check boxes 2 & 3 below.
• If the household size on the tax return is not an accurate representation for purposes of reporting within the
Choice Scholarship Program, the parent/guardian must complete the Household Summary Form.

Choose all that apply:


q I will submit my 2022 Federal Tax Return (first page of 1040) because it provides an accurate picture of my
household size and income. (One 1040 includes all income & indicates accurate household size)
q My 2022 Federal Tax Return does not accurately depict my household income for purposes of determining
eligibility in the Choice Scholarship Program. Please send me the Household Summary Form for my completion.
q My 2022 Federal Tax Return does not accurately depict my household size for purposes of determining
eligibility in the Choice Scholarship Program. Please send me the Household Summary for my completion.

I have reviewed all the requirements to determine household size and household income in its entirety and with
my signature I verify that I have accurately disclosed this information on the Scholarship Intent Form to determine
my student’s eligibility for the Choice Scholarship Program.
_______________________________________________
Printed Name of Parent or Guardian

_______________________________________________ ____________________________
Signature of Parent or Guardian Date Signed

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