Potomac Conference Education Foundation – Funding Adventist Education for Eternity

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Student Information

First Name *

Last Name *

Birthdate *

Address 1 *

Address 2

City *

Zip / Post Code *

Phone *

Parent/Guardian Information

Parent First Name *

Parent Last Name *

Number of Persons in Household *

Total income listed on 2015 Federal Tax Return *

Parent/Guardian Email *

Assigned Public School Division * Help Text

School your child attended last school year? Include city and state if not in Virginia: *

Did the student live out of state last school year? *

Was the student enrolled in a Virginia public school either semester last school year? *

Did the student receive a Virginia Education Tax Credit Scholarship last year? *

Does the student have a disability? *

"Eligible student with a disability" means a student (i) for whom an individualized educational program has been written and finalized in accordance with the federal Individuals with Disabilities Education Act (IDEA), regulations promulgated pursuant to IDEA, and regulations of the Board of Education; (ii) whose family's annual household income is not in excess of 400 percent of the current poverty guidelines; and (iii) who otherwise is a student as defined in this section.

Families requesting tax credit scholarships must complete an application with FACTS. Please also indicate that you want Potomac Conference Education Foundation to receive the report.

Have you submitted an application to FACTS? *

I/We certify that the information in this application is true and complete to the best of my/our knowledge. Falsification of information will result in disqualification and/or termination of any scholarship granted.

I certify that, if funds are received, they will be used for the educational purposes for which they are granted.

I/We understand that the information contained in the application may be shared with the scholarship committee, the Foundation's Board of Directors, and Foundation staff.

I/We will also supply additional information if requested by Potomac Conference Education Foundation.

Signature *

Date *

The information collected in this form is used exclusively to determine a student's eligibility for Virginia's Education Improvement Scholarships Tax Credits Program. The information may be used to send you information and updates pertaining to your application. This information is submitted via a secure online form and is only shared with third parties necessary to administer the program.

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