DISABLED/DISPLACED STUDENT SCHOLARSHIP APPLICATION LEXIE S LAW School Year 2013/2014

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1 Instructions: 1) Complete the eligibility process with the Arizona Department of Revenue. After receiving approval / eligibility letter, then complete this application. ADR Eligibility Click HERE. 2) After receiving ADR approval / eligibility letter, then complete this application. There are 5 sections, each must be fully completed! Please type or print clearly. 3) Use one application per child. 4) or fax the completed application with the Arizona Department of Revenue Eligibility Letter to Arizona Leadership Foundation at: Fax: (480) STUDENT NAME Section 1A: A qualified student for the Lexie s Law scholarship, is a student who has (Check boxes that apply): An Individual Education Plan (IEP) or a 504 plan from an Arizona public school (can be current or expired), or Been placed, at some point in the Arizona foster care system. Section 1B: Qualified applicants must also meet one of the following requirements (Check boxes that apply): Attended a public school as a full-time student for at least 90 days of the prior fiscal year or one full semester and then transferred from the public school to a private school; or Is enrolling in a private school kindergarten; or Is enrolling in a private preschool program for students with disabilities; or Is a dependent of a member of the armed forces of the United States who is stationed in Arizona pursuant to military orders; or Received a scholarship in the 2008/2009 academic year from the Arizona Department of Education; or Qualified for a scholarship under one of the above criteria if the child continued to attend a private school in subsequent years. 1

2 Section 2: Student Name: Date of Birth First Middle Last Gender: Female Male Address City, State, Zip Parent/Guardian Name(s) Phone Number: Address: ( is our preferred contact method to notify you of scholarship status and to ask any questions we might have) School Attending: Child s Grade: Please list the name of the school your child attended last school year: If this was a public school, you must include the public school verification letter with your application. Has the applicant received Empowerment Scholarship Money (ESA) from the Arizona Department of Education for the current school year (2013/2014)? (Please check appropriate box) Yes No Please list additional personal or economic factors (if any), that you feel the Arizona Leadership Foundation should take into consideration while reviewing this application: 2

3 Section 3: Financial Information Please note if income is weekly, monthly, yearly etc. 1) Household member s full name (first & last name of each person living in household) 2) Gross income from work (Amt. earned before taxes & deductions) Welfare, Alimony, Child support payments Pension or retirement All other income 3)Check box if no income per family member EXAMPLE: John Doe $800/Monthly $100/Month $200/Monthly $200/Monthly 3

4 Section 4: Information Release Form for Disabled/Displaced Students (Lexie s Law) For purposes of the Disabled/Displaced Scholarship Program, I permit the Arizona Department of Revenue to provide information in regards to eligibility status and scholarship limitation for (student name) to the following School Tuition Organization: Arizona Leadership Foundation Ariana Muth Fax: (480) Parent / Guardian Signature Parent / Guardian Printed Name Date Arizona Department of Revenue Contact Information: Karshannon Gene Office of Economic Research and Analysis (602)

5 Section 5: Please check that you have submitted these documents / forms with your application: Approval / Eligibility Letter from the Department of Revenue (MANDATORY) Military Orders showing your assignment to the State of Arizona (if applicable) Public School verification letter (if applicable) I agree to the following (please check): Financial aid awarded to the applicant (s) must be used as allowed by Arizona law solely for tuition expenses at a qualified private school of the applicant s choice. Any potion unused must be returned by the school to the Arizona Leadership Foundation for reallocation. Arizona Leadership Foundation has absolute and sole discretion in awarding financial aid. Financial aid is distributed without regard to ethnicity, sex, or handicap. Financial aid is only for the current academic year and continuing aid is based upon the applicant s eligibility and funds available for disbursement. A school tuition organization cannot award, restrict or reserve scholarship solely on the basis of donor recommendation. A taxpayer may not claim a tax credit if the taxpayer agrees to swap donations with another taxpayer to benefit either taxpayer s own dependent. The applicant meets the criteria set forth in Section 1A and Section 1B. Parent / Guardian Signature Parent / Guardian Printed Name Date 5

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