Park District of Oak Park

4 Income is defined as any monies earned before any deductions such as income taxes, social security taxes, insurance premiums; charitable contributions, and bonds. It includes the following: (1) Monetary compensation for services, including wages, salary, commissions or fees; (2) net income from non-farm self employment; (3) social security; (4) dividends or interest on savings or bonds or income from estates or trusts; (5) net rental income; (6) public assistance or welfare payments; (7) unemployment compensation; (8) government civilian employment or military annuities; (9) private pensions or annuities; (10) alimony or child support payments; (11) regular contributions from persons not living in the household; (12) net royalties ; and (13) other cash income. Other cash income would include cash amounts received or withdrawn from any source including savings, investments, trust accounts, and other resources that would be available. OR If your family is faced with extraordinary bills, obligations or other responsibilities please indicate below, explaining that because of these, payment of fees is not possible at this time. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ I ____________________________ hereby certify that all information on the application is true and accurate. Scholarships are legally recoverable if paid and awarded based on false information supplied by the applicant. The submission of false information will nullify any request for waiver of program fees. ___________________________________________ _______ / _______ / 20___ Signature of Applicant's Parent/Legal Guardian Date Note: Applicant's income will be verified with tax return, paycheck stub, or other appropriate document. Note to Parent/Guardian: Please circle the size of your household and your total household income below, and sign to verify your income. Household income must be equal to or less than the amounts listed for each pay period for your child to be eligible for the scholarship. You will need to present documentation verifying your income. Scholarship Program 2022 January 2022-December 2022 Funded by the Park District of Oak Park & Oak Park Township Circle Household Size and Income: Tier 1 (Fees Covered) Scholarship 75% / 25% Participant Tier 2 (Fees Covered) Scholarship 55% / 45% Participant Tier 3 (Fees Covered) Scholarship 35% / 65% Participant Household Size Annual Income Annual Income Annual Income 1 16,744 23,828 30,912 2 22,646 32,227 41,808 3 28,548 40,626 52,704 4 34,450 49,025 63,600 5 40,352 57,424 74,496 6 46,254 65,823 85,392 7 52,156 74,222 96,288 8 58,058 82,621 107,184 Each add'l family member add +5,902 +8,399 +10,896

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