FINANCIAL AID APPLICATION
2013-2014

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PLEASE READ

Additional information and instructions are available in the 2013-2014 Financial Aid Prospectus. The Prospectus is available in PDF format via the MSM website. All fields are required. If a question doesn't apply to you, please enter N/A or 0, if a dollar amount is requested.

Contact Information

* Today's Date

* Academic Program (Please check one):

* 1. Last Name

* First Name

Middle Initial

* 2. Social Security Number

* 3. Date of Birth (ex. 01/01/1997)

* 4. Current Mailing Address

* Apt # or P.O. Box

* City

* State

* Zip Code

* 5. Permanent Mailing Address

* Apt # or P.O. Box

* City

* State

* Zip Code

* 6. E-mail address

* 7. Citizenship Status

* 8. Legal State of Residence

* 9. Home Telephone

Cellular Telephone

Pager

* 10. Have you ever been a member of the Boys & Girls Clubs?

If yes, how many years?

* 11. Have you ever participated in a Health Careers Opportunity (HCOP)?

11a. If yes, please list the name of the program:

11b. Please list where you participated in this program (i.e., school, college/university, city, state):

* 12. Do you plan to practice primary care?

* 12. If yes, which field?

* 13. What high school did you attend?

* 13a. City

* State

* 14. Marital Status

* 15. Dependents

If yes, select the number of dependents:

Ages of dependents:

Financial Aid Information

16. List all other Financial Aid that you have applied for (include financial assistance from parents, spouse, spouse's parents, other relatives, etc.). Please write "N/A", if not applicable.

* Aid Source

* Amount

* Aid Source

* Amount

* Aid Source

* Amount

* 17. Student's 2012 untaxed income and benefits (write "N/A" if you did not receive any untaxed income in 2012):

Spouse's Information

If you are single, skip this section.

18. Spouse's Last Name

Spouse's First Name

19. Spouse's Age

20. Spouse's 2012 income earned from work (taxable an nontaxable income):

20a. Will your spouse be a student in 2013-2014?

20b. Name of Institution

State

20c. Has spouse applied for financial aid?

21. Comments (upload attachment below, if necessary):

0/2000 characters

Upload attachment(s)

Federal Tax Information

* 22. Did you (spouse, if applicable) file a 2012 Federal Tax Return?

If you answered yes, submit a copy of your tax return, including W-2 and/or 1099 forms received to verify total amount of income earned for the 2012 tax year.

If you answered no, complete the Student Non-Filer Certification form below.

STUDENT NON-FILER CERTIFICATION FOR 2012
(Include spouse, if applicable)

Note: Whether you filed a tax return or not, you must submit copies of all W-2 and/or 1099 forms received for the 2012 tax year.

Student and spouse (if married) who will not file a 2012 Federal Income Tax Return must complete this form.

Please complete both sections of the form. Enter “0” if you did not receive any taxable and/or nontaxable income.

The information below pertains to (check one):

I (we) did not and will not file a 2012 Federal Income Tax Return, IRS Form 1040, 1040A, or 1040EZ for the following reasons (check one):

Received no taxable income

Taxable income received was less that the amount required for filing a tax return (list amount of taxable income):

My (our) total income (taxable and/or nontaxable) for 2012 (January 1 - December 31) was

Source of income

* 23. Do you plan to provide parent income information, which is required in order to be considered for institutional aid (i.e., scholarships, grants, low interest loans)?

Yes (Complete the Family Information section below and proceed to #24)

No (Proceed to Closing Section at the end)

FAMILY INFORMATION

List the people that your parent(s) will support between July 1, 2013 and June 30, 2014. Include:

• Yourself

• Your parent(s) and/or stepparent(s)

• Your parent(s)/stepparent(s) dependent children (if your parent(s) provide more than half support, or if they would be required to give parental information when applying for aid.)

Include other people as part of your family only if:

• they lived with your parent(s)/stepparent(s) and received more than half their support from your parent(s)/stepparent(s) at the time you completed your student aid application

AND

• they will continue to receive more than half their support from July 1, 2013 through June 30, 2014.

Write the names of all family members. Also write in the name of the college for any family member (excluding parents) who will be attending college at least half-time between July 1, 2013 and
June 30, 2014 and will be enrolled in a degree or certificate program.

	Full Name	Age	Relationship	College
Family

* 24. Did your parents file a 2012 Federal Income Tax Return?

Yes (Submit a copy of their tax return including any W-2 and/or 1099 forms received to verify total amount of income earned for the 2012 tax year.)

No (Proceed to the Parent Non-filer Certification form below.)

PARENT NON-FILER CERTIFICATION FOR 2012
(PARENT(S), STEPFATHER, STEPMOTHER, OR GUARDIAN)

Note: Whether you filed a tax return or not, you must submit copies of all W-2 and/or 1099 forms received for the 2012 tax year.

Parent(s) who will not file a 2012 Federal Income Tax Return must complete this form.

Please complete both sections of the form. Enter “0” if you did not receive any taxable and/or nontaxable income.

The information below pertains to (check one):

I (we) did not and will not file a 2012 Federal Income Tax Return, IRS Form 1040, 1040A, or 1040EZ for the following reasons (check one):

Received no taxable income

Taxable income received was less that the amount required for filing a tax return (list amount of taxable income):

My (our) total income (taxable and/or nontaxable) for 2012 (January 1 - December 31) was

Source of income

Closing Section

Review your application for completeness, accuracy, and submit. Review the application instructions and checklist for supporting documentation (i.e. filed tax returns for the current year) that must be submitted directly to the Student Fiscal Affairs Office at the address below.

Be sure to download the Selective Service Affidavit form (males only). Sign and mail it to:

Student Fiscal Affairs
Morehouse School of Medicine
720 Westveiw Drive
Atlanta, GA 30310
404-752-1053 (fax)
E-mail:studfisc@msm.edu

Deadline dates vary by program and class year. Please review deadline dates on the MSM website, specific to your program and class year. You may refer to the Application Deadlines page for additional information.

Students who fail to follow the instructions for this application and/or do not submit the required information by the established deadline date will not receive maximum consideration for institutional funds.

Failure to submit all required schedules and verify total amounts of income earned for student and/or parents will prevent you from receiving priority consideration for institutional grants/scholarships support.

* Signature

* Indicates Response Required

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