Application Signature Page for Application # 383665

Please note: While you signed an electronic version of this form, the hard copy is required. Please initial and sign where indicated and return with any other documents that were requested.

INITIAL HERE -> _____ I certify that all the information provided in this                                        application and all supporting documentation is true,                                       correct and complete and that ALL household income                                       has been reported. I understand that intentional                                       misrepresentation could result in the scholarship being                                       denied or revoked and in criminal prosecution.

                                       Per Florida Statute SB2126; “Owner or operator” includes:                                        An owner, operator, superintendent, or principal of an                                         eligible private school or a person with equivalent                                        decision making authority over an eligible private school.

                                       An eligible nonprofit scholarship-funding organization:                                        May not …provide scholarships to a child of an owner                                        or operator.

INITIAL HERE -> _____ I certify that no parent/guardian of a child on this                                        application is an owner, operator, principal, or person                                        with equivalent decision-making authority of an eligible                                       private school.

INITIAL HERE -> _____ I agree to follow the rules and responsibilities for                                       parents as they apply to the program as set forth in the                                       Parent Handbook.

SIGN HERE ->________________________________________________________Arisleidy Pena                                     DATE

SIGN HERE ->________________________________________________________

SigPage_2015

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Arisleidy Pena • If weekly: Provide a copy of your most recent four (4) in a row pay check stubs / LES showing your GROSS wagesIf every-other week: Provide a copy of your most recent two (2) in a row pay check stubs / LES showing your GROSS wagesIf two times a month: Provide a copy of your most recent two (2) in a row pay check stubs / LES showing your GROSS wagesIf once a month: Provide a copy of your most recent pay check stub / LES showing your GROSS wages If once a year: Provide a copy of your previous year’s W-2 or 1099If other: Provide an official letter from your employer stating the frequency of your wages and the total current gross monthly amount you receive

• Provide your application payment. You can pay this fee online using a credit/debit card.

• Provide your initials on the signature page where indicated by the arrows. Your initials are the first and last letters of your name. For example: John Smith would be J.S.

• Provide the signature page, signed by you, that will print when you finish your application.

• Provide a copy of a current U.S. federal or state issued ID with a signature. Examples of an ID include: United States Passport, U.S. Military ID, Driver’s license, and state identification card.

• Please have someone who does NOT live in your house complete and sign the Step Up For Students form #1050- HC. This form will print when you complete your application. In addition, provide a copy of ONE document from the list below. The document must include your name and address:• Current month’s statement from SSI OR,• Current month’s statement from VA OR,• Current month’s SNAP statement OR,• Current month’s statement from TANF OR,• Current S8/HUD lease OR,• Current Mortgage, monthly mortgage statement, residential lease agreement OR,• Deed OR,• Current Paystubs with address listed OR,• Current Medical or health care benefits or enrollment statement with address listed OR,• Current homeowner’s or renter’s insurance policy or bill OR,• Current automobile insurance policy or bill OR,• Utility bill (water and/or electric) not more than two months old

Household Member Required Documents

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Benjamin Cruz• Provide a copy of ONE document from the list below.

The document must include the name and address of this child / student:• Current month’s statement from SNAP OR,• Current month’s statement from TANF OR,• Current Medical or health care benefit or enrollment statement OR,• Florida Kidcare or Medicare Statement OR,• Public school transcripts OR,• Official court custody documents showing the custodial parent’s name

Dariel Pena• Provide a copy of ONE document from the list below.

The document must include the name and address of this child / student:• Current month’s statement from SNAP OR,• Current month’s statement from TANF OR,• Current Medical or health care benefit or enrollment statement OR,• Florida Kidcare or Medicare Statement OR,• Public school transcripts OR,• Official court custody documents showing the custodial parent’s name

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#1050-HCVerification of Household Composition

Step Up For Students

Application # 383665

PLEASE ASK A FRIEND, NEIGHBOR, PASTOR, ETC. TO COMPLETE THIS FORM. THIS PERSON MUST NOT BE RELATED TO YOU AND CANNOT LIVE

WITH YOU. 

Arisleidy Pena619 Whispering Cypress Ln

Orlando Florida, 32824

Do the people listed below live at this address? YES? / NO *

*If they do not live at the address listed above, provide the address of the home where they live:

Street Address:_________________________________________________

List ALL adults and children who live at the address listed above.

Please indicate their ages and relationship to  Arisleidy Pena              

Household Member’s Name                                      Relationship to                                   Age

Arisleidy Pena

1 ______________________________________   ___________________________   _____________

2 ______________________________________   ___________________________   _____________

3 ______________________________________   ___________________________   _____________

4 ______________________________________   ___________________________   _____________

5 ______________________________________   ___________________________   _____________

6 ______________________________________   ___________________________   _____________

7 ______________________________________   ___________________________   _____________

8 ______________________________________   ___________________________   _____________

9 ______________________________________   ___________________________   _____________

10______________________________________   ___________________________   _____________

Under penalties of perjury, I certify that the information presented is true and accurate to the best of my knowledge and belief. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the denial of the scholarship application or revocation of a scholarship award.

_________________________________________________________________________________________________Name of Person Completing Form (please print clearly)                                         Phone #                           Date

_________________________________________________________________________________________________

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Street Address of Person Completing Form                                               City                      State              Zip

_________________________________________________________________________________________________Signature of Person Completing Form                         Relationship of Person Completing Form to Arisleidy Pena

SUFS1050HHCeng.2015

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INSTRUCTIONS FOR SENDING YOUR DOCUMENTS TO STEP UP FOR STUDENTS

1. The following documents must be sent in as part of your application:

• The signed and initialed Application Signature Page

• All requested supporting documentation

◦ Including any required Step Up For Students Statement that must be signed

2.    Please do the following:

• Write your Application ID number on the upper, right hand corner of each document (if it is not printed)

◦ Your Application ID number is: 383665

• Put the documents in the following order

◦ Application Signature Page

◦ Student Report Card/s (if applicable)

◦ Food Stamp Documents (if applicable)

◦ Income documents (pay stubs, unemployment documents, etc.)

◦ Child Support Documents

◦ Court Documents

◦ Tax Return (if applicable)

◦ Step Up For Student Statements

◦ Any other documents

3.    Application Submission Options:

• FAX

◦ If you fax your documents, you must use the Step Up For Students

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Fax Cover Sheet. The cover sheet includes your Application ID Number, your name, and the fax number to use for submitting your documents.

• UPLOAD

◦ You can also upload the documents directly to your application. To do this, please log in to your online Step Up account, click on where it says "Print and send documents" and follow the instructions on this page.

4.    Checking your application status:

• You can check your application status online at www.stepupforstudents.org

◦ On the home page, click on “Logins”

◦ Under “Parent Login” choose the first option which says:To continue an application you have started, or to check the status of your application, please click here.

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FAX COVER SHEET

TO: Document Processing CenterFAX NUMBER: 904-592-6548

APPLICATION ID NUMBER: 383665

FROM: Arisleidy Pena

LAST FOUR NUMBERS OF PRIMARY PARENT’S SOCIAL SECURITY NUMBER:           

NUMBER OF PAGES IN THIS FAX, INCLUDING THIS COVER PAGE: _____________________

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