SCI-Arc Admissions Office 960 East 3rd Street Los Angeles, CA 90013

Financial Statement & Scholarship Application

1. Applicant ___________________________________________________________________________________ Legal Name / Last First Middle Initial ___________________________________________________________________________________ Address City State Zip Country (if other than U.S.) ___________________________________________________________________________________ Email address Phone Number 2. Mother / Stepmother / Female Guardian ___________________________________________________________________________________ Legal Name / Last First Middle Initial ___________________________________________________________________________________ Address City State Zip Country (if other than U.S.) ___________________________________________________________________________________ Email address Phone Number 3. Father / Stepfather / Male Guardian ___________________________________________________________________________________ Legal Name / Last First Middle Initial ___________________________________________________________________________________ Address City State Zip Country (if other than U.S.) ___________________________________________________________________________________ Email address Phone Number 4. Child lives with: (check one below) ____ Mother & Father ____ Mother Only ____ Father Only ____ Other (please specify below) 5. Tax Information – Domestic applicants only (Domestic applicants located internationally, please proceed to Section 5A.) (Please fill in the questions below using your most recent completed Federal Income Tax Returns. Please include signed copies of parent’s 2013 income tax statements with this application.) Total number of exemptions (IRS Form 1040 or 1040A): IRS Adjusted Gross income (IRS Form 1040 or 1040A): $ Federal income Tax paid (IRS Form 1040 or 1040A): $ Itemized deductions (Form 1040, Schedule A or write 0 if no deductions): $ Nontaxable Income:

DID Financial Statement & Scholarship Application, page 2 Social Security benefits: $ Aid to Families with Dependent Children (AFDC or ADC): $ Veterans Benefits: $ Other nontaxable income: $ Medical and Dental expenses not paid by insurance $ Wages, salaries, tips – mother/stepmother: $ Wages, salaries, tips – father/stepfather: $ Interest Income: $ Dividends: $ Taxable Income other than wages, interest and dividends: $ Adjustments to Income (Give only IRS allowable amounts for employee business expenses, alimony pay, moving expenses, sick pay, Keogh or IRA payments, and forfeited interest): $ Nontaxable income: $ Other Expected Income not listed above, including children’s income: $ (Please include signed copies of parent’s 2013 income tax statements.) 5A. Personal Financial Statement Please describe your basic means of financial support while living overseas. Currency What is the exchange rate of your nation’s currency to US dollars? Is there any restriction on the exchange and release of funds to the US? □ No □ Yes (describe restriction) Financial Information List all amounts in US dollars. Give best estimates as of the date you complete the form. If none, enter zeros. Assets (as of date of completing form) Student (or parent if student is a minor) Bank accounts (savings and checking) Other investments (stocks, bonds, etc.) Interest in trusts or estates

DID Financial Statement & Scholarship Application, page 3 6. Education Expenses Please list below all family members who will be enrolled in school or college (for coming school year)

Name of Student Age Relationship to applicant

School Education Expense borne by parent

7. Asset Information For Homeowners Only: Year home purchased: Purchase price: Unpaid Mortgage: Total in savings accounts: Total in checking accounts: Real estate investments: $ $ worth debt Other investments: $ $ worth debt (For Business Owners Only) Business: $ $ worth debt

8. Divorced or Separated Parents (For parents who are receiving alimony and/or child support): Total amount of child support expected for all children this year: $ Total amount of alimony expected this year: $ Who claims child(ren) as dependent(s)? Name: 9. Special Circumstances Use this area to describe any special circumstances which affect your ability to pay the enrollment fee and which you believe should be considered.

DID Financial Statement & Scholarship Application, page 4 10. Certification: I certify that answers given herein are true and correct to the best of my knowledge. I (We) agree to give proof of the information that I (we) have given on this form. I (We) realize that this proof may include a copy of my (our) Income Tax Forms. Parent/Guardian printed name Parent/Guardian Signature Date