PRIVATE SCHOOL AID SERVICE Student Aid Form 2008-2009 Catholic Elementary Schools of Brooklyn and Queens Annual Catholic Appeal Catholic Education Scholarship Fund • THIS APPLICATION IS FOR FAMILIES OF STUDENTS CURRENTLY ENROLLED OR PLANNING TO ENROLL IN PRE-K-8 CATHOLIC SCHOOLS IN BROOKLYN OR QUEENS. • TO BE CONSIDERED FOR A SCHOLARSHIP FOR THE 2008-2009 SCHOOL YEAR, YOU MUST FILL OUT THIS APPLICATION, EVEN IF YOU HAVE COMPLETED AN APPLICATION IN THE PAST. • PLEASE NOTE: IN THE PAST, THE AVERAGE FAMILY INCOME OF RECIPIENTS WAS $26,142 FOR A FAMILY OF FOUR. THE AVERAGE SCHOLARSHIP WAS $700. • ALL INFORMATION AND DOCUMENTATION PROVIDED ON THIS FORM IS KEPT CONFIDENTIAL. NO OTHER AGENCY WILL SEE OR RECEIVE ANY INFORMATION ABOUT THIS APPLICATION OR ITS ATTACHMENTS. (Please make sure all documentation is copied on regular 8 1/2 x 11 paper.) • THIS FORM MUST BE POSTMARKED NO LATER THAN MARCH 10, 2008. To check the processing status of your application, go to www.psas.org. Keep a copy of this application. Mail application with a check or money order in the amount of $18.00 to: Private School Aid Service Form #110 (2007) P.O. Box 770728 Lakewood, Ohio 44107 (All returned checks will incur an additional fee of $25.00) PARENT LAST NAME___________________________________________________________________________________ STUDENT LAST NAME_______________________________________________________________________________________ _ Form #110 (2007) Student Aid Form • 2008 – 2009 • IMPORTANT: Print clearly and neatly with a ball point pen • PARENT, GUARDIAN or OTHER ADULT RESPONSIBLE FOR TUITIONA Check one: • Father • Mother • Stepfather • Stepmother • Other Adult Last Name First Name MI ____________________________________________________ _________ ( __ _ _ _ _ _ _ _ _ _ _ _) ___________________________________________________ Social Security Number Age (Area Code) Home Phone Address Apt. # PARISH CODE (see list) City State Zip ( _ ) _________________________________________________ _____________________ ________ __________ (Area Code) Work Phone E-mail address ________________________________________ May PSAS contact you at work ifEmployed by How Long? there are questions? • Yes • No • If you are self-employed, check this box and refer to Section K of this form. PARENT, GUARDIAN or OTHER ADULT RESIDING WITH PARENT AB Check one: • Father • Mother • Stepfather • Stepmother • Other Adult Last Name First Name MI ____________________________________________________ _________ ( __ _ _ _ _ _ _ _ _ _ _ _) ___________________________________________________ Social Security Number Age (Area Code) Home Phone Address Apt. # PARISH CODE (see list) City State Zip ( _ ) _________________________________________________ _____________________ ________ __________ (Area Code) Work Phone E-mail address ________________________________________ May PSAS contact you at work ifEmployed by How Long? there are questions? • Yes • No • If you are self-employed, check this box and refer to Section K of this form. DEPENDENTS Number of dependent children who will attend a tuition charging school: Pre-K, elementary school, secondary school, or college in the fall of 2008 _____C Student 1. Last Name First Name MI Age Grade in the Fall of 2008: Check One: • Caucasian • African-American • Hispanic • Asian • Other Check One: • Catholic • Non-Catholic Amount we feel we can pay Toward Tuition (Per Year) $ Name of School Student plans on attending in 2008-2009: City State Tuition $ School Code # (see list) Student 2. Last Name First Name MI Age Grade in the Fall of 2008: Check One: • Caucasian • African-American • Hispanic • Asian • Other Check One: • Catholic • Non-Catholic Amount we feel we can pay Toward Tuition (Per Year) $ Name of School Student plans on attending in 2008-2009: City State Tuition $ School Code # (see list) Student 3. Last Name First Name MI Age Grade in the Fall of 2008: Check One: • Caucasian • African-American • Hispanic • Asian • Other Check One: • Catholic • Non-Catholic Amount we feel we can pay Toward Tuition (Per Year) $ Name of School Student plans on attending in 2008-2009: City State Tuition $ School Code # (see list) • Please check if additional dependents are listed on a separate sheet. HOUSEHOLD INFORMATIOND 1. Number of individuals who will reside in my/our household 2. Current marital status/housing arrangement of Parent/Guardian A: during the 2008-2009 school year: a. • Single, never Married* d. • Divorced* g. • Residing w/Significant Other Parents/Guardians _ Children _ Other _ b. • Married e. • Remarried* h. • Other: ______________ *If Other, please explain relationship to Parent _________________________ c. • Widowed f. • Separated* ______________________ *If Divorced, Remarried, Separated or Single, please complete Section E. DIVORCED, SEPARATED OR SINGLE PARENTS (TO BE COMPLETED BY PARENT OR GUARDIAN LISTED IN SECTION A)E 1. Date of separation (Month/Year) ____________________________________________________________________________________ 5. Who claimed student as a tax dependent in 2007? ____________________________ 2. Date of divorce (Month/Year) _________________________________________________________________________________________ 6. Who is responsible for the tuition for the dependent(s) listed in Section C? 3. Non-custodial parent _____________________________________________________________________________________________________ Father % Name ______________________________________________ • Last Name First Name MI 4. Do you receive or pay child support? • Receive $_ per year • Mother % Name ______________________________________________ • Pay $_ per year • Other % Name ______________________________________________ * • Neither *If tuition is shared, each responsible party must complete a Student Aid Form (SAF). Form #110 (2007) TAXABLE INCOMEF HOUSING INFORMATION (DO NOT LEAVE BLANK)H 21. Do you rent or own your residence? • Rent • Own (go to line 22) 22. If renting, what is the monthly rental payment? $ _ _ a. Amount paid by household $ _ per month Actual 2007 Estimate 2008 The 2007 federal tax return for student’s household was: Filed Not filed yet (See Required Documentation section) I/we do not file. I/we only receive non-taxable income 1. Total number of exemptions claimed on Federal Income Tax form: 2. Parent/Guardian A total taxable income from W-2 wages. (List total income for Parent A only) $ __ 3. Parent/Guardian B total taxable income from W-2 wages. (List total income for Parent B only) $ __ 4. Net business income* from self-employment, farm, rentals, and other businesses. (*go to Section K) (Attach Schedule C, E, and/or F from your IRS 1040) $ __ See 2007 1040 lines 12, 17 and 18 5. Other non-work taxable income from interest, dividends, alimony, unemployment, and nonbusiness income. $ __ See 2007 1040 lines 8a, 9a-11, 13, 14, 15b, 16b, 19-21 See 2007 1040A lines 8a-14b 6. Allowable “Adjustments to Income” as reported on your IRS 1040, 1040A or 1040EZ. $ __ See 2007 1040 line 36 or 1040A line 20 7. Total “Adjusted Gross Income” as reported on your IRS 1040, 1040A or 1040EZ. $ _ See 2007 1040 line 37 or 1040A line 21 8. Total Tax Paid as reported on your IRS 1040, 1040A or 1040EZ. $ _ See 2007 1040 line 63 or 1040A line 37 9. Medical/dental expenses as reported on Schedule A line 1 of your IRS 1040 $ _ _ _$_ _ _$_ _ _$_ _ _$_ _ _$_ _ _$_ _ _$_ _ _$_ b. Amount paid by other source(s) $ _ per month ASSETS & INVESTMENTS (AS OF 12/31/07)I _ 23. Total amount in cash, checking, and savings accounts $ _ _ 24. Total value of money market funds, mutual funds, stocks, bonds, CDs, or other securities $ _ _ 25. Total value of IRA, Keogh, 401K, SEP or other retirement accounts $ _ _ 26. If you own real estate other than your primary residence, a. What is the fair market value? $ _______________ _ b. What is the amount still owed? $ _ _ 27. Do you own a business? • Yes • No If Yes, please go to Section K. _ a. What is the fair market value of your business? $ _ b. What is the amount still owed? $ _ _ UNUSUAL CIRCUMSTANCESJNON-TAXABLE INCOMEG List the total amount received from 1/1/07-12/31/07 for all recipients in household. DO NOT list monthly amounts. 10. Child support $ _ _ 11. Cash Assistance (TANF) $ _ _ 12. Food Stamps $ _ _ 13. Social Security income (SSI/SSD, etc.) (Provide documentation for all recipients in household.) $ __ _ 14. Student loans and/or grants received for PARENT’s education. (Not college attending dependents or students listed in Section C.) a. total received in 2007 $ b. total used for household expenses $ _ _ 15. Housing Assistance (Sec. 8, HUD, Parsonage, etc.) $ _ _ 16. Other non-taxable income (Workers’ Comp., Disability, Pension/Retirement, etc. Identify source(s) in Section L) $ __ _ 17. Loans/Gifts from friends or relatives $ _ _ 18. Personal Savings/Investment Accounts used for household expenses $ _ _ 19. Other Scholarships $ _ _ 20. Total non-taxable income for 2007 $ per year per year* per year* per year* per year* per year* per year* per year per year Check all that apply to your situation: a. • Loss of job b. • Recent separation/divorce c. • Change in family living status d. • Change in work status e. • Bankruptcy f. • College expenses g. • Income reduction h. • Illness or injury i. • Death in the family j. • Shared custody k. • High debt l. • Child support reduction m. • Medical/Dental expenses n. • Shared tuition o. • Other (Explain in Section L) *You must provide 2007 YEAR-END documentation for items 11-16; either a Year-End Statement from the appropriate Public Agency, or documentation showing totals from 1/1/07 - 12/31/07. per year per year Go to next page  Parent/Guardian A: SS# – – Print Name BUSINESS INCOME ESTIMATE (2007 TOTALS) (If you have not filed your 2007 Tax Return, and are Self-Employed, Own a Business, Rental Property and/or Farm DO NOT LEAVE BLANK)K Schedule C Schedule E Schedule F 1. What is your total estimated GROSS business taxable income? $_____________ $_____________ $_____________ 2. What is your total NET business taxable income/loss? $_____________ $_____________ $_____________ 3. If your business pays your home rent or mortgage, what is the annual total? $_________________________ 4. If your business pays for your personal automobile, what is the annual total? $_________________________ 5. If your business pays any portion of other personal expenses, list total amount and explain in SECTION L. $_________________________ 6. If you own rental property: What was the total amount of Rental Income received? $_________________________ EXPLANATIONS (USE THIS SPACE TO EXPLAIN ANY ANSWERS WHICH MAY NEED CLARIFICATION)L CERTIFICATION, AUTHORIZATION AND DOCUMENTATION CHECKLISTM WHAT IS NEEDED TO PROCESS THIS APPLICATION (IF ANY OF THE FOLLOWING IS MISSING, YOUR APPLICATION WILL NOT BE CONSIDERED COMPLETE) 1. This application form filled out in its entirety, SIGNED AND DATED BELOW by the Parent or Guardian listed in Sections A and B. 2. A check or money order made payable to PRIVATE SCHOOL AID SERVICE in the amount of $18.00. This is a non-refundable application fee. 3. IF YOU HAVE FILED A 2007 IRS FORM 1040: IF YOU HAVE NOT YET FILED A 2007 IRS FORM 1040: A complete photocopy of your most recent Form 1040, 1040A or 1040EZ (as filed with the IRS, with all Schedules. 2007 W-2 Forms, 2007 1099/1099R, or 1098 Forms) for any wage- IF YOU DO NOT FILE AN IRS FORM 1040 AND RECEIVE ONLY NON-TAXABLE INCOME: Photocopies of your 2007 YEAR-END Social Services statement (TANF, etc.), Food Stamp documentation, Housing Assistance A complete photocopy of your 2007 Form 1040, 1040A, or earning adult residing with the applicant(s). If this application 1040EZ (as filed with the IRS, including all Schedules). documentation, Student Loans and/or grant documentation for 2007 W-2 Forms, 2007 1099/1099R, or 1098 Forms for any is submitted after April 15, 2008, you must provide a copy of the 2007 Extension for Filing Request, as approved by the parent’s education, Social Security income statements showing TOTAL AMOUNT received in 2007 for ALL members of the wage-earning adult residing with the applicant(s). IRS and a copy of your last filed tax return. household. SIGN HERE I/we declare that the information on this form is true, correct, and complete to the best of our knowledge. I/we authorize PRIVATE SCHOOL AID SERVICE to return this form and all attachments only to the schools and agencies named in Section C under contract with PSAS. • . Parent/Guardian A ____________________________________________________________________________________ Date ______________________ Parent/Guardian B _________________________________________________________________________________ Date ___________________ This Student Aid Form (SAF), all attachments and an analysis of your SAF are sent only to the school(s) or agencies contracting with PSAS. You will not receive results from PSAS. No other agency will see or receive any information about this application or its attachments. PRIVATE SCHOOL AID SERVICE, P.O. Box 770728, Lakewood, Ohio 44107-0034 Copyright ©2008 Private School Aid Service INTRODUCTION DIVORCED, SEPARATED OR SINGLE PARENTS E Detach here PRIVATE SCHOOL AID SERVICE (PSAS) is under contract with the school, school system, or organization from which you obtained this application for tuition assistance. Our purpose is to provide a reasonable assessment of the ability of each family to pay for the education of their children at private and independent elementary and secondary schools. Your Student Aid Form, all attachments, and an analysis of your SAF are sent only to the school(s) or agencies contracting with PSAS. No other agency will receive any information about this application or its attachments. PRIVATE SCHOOL AID SERVICE does not make any decisions about recipients and amounts of financial aid awarded. Recipients and amounts of aid are determined by the designated school or agency. YOU WILL NOT RECEIVE RESULTS FROM PRIVATE SCHOOL AID SERVICE. INSTRUCTIONS PARENT, GUARDIAN OR OTHER ADULT A & B This form should be filled out by the parent, guardian or other adult responsible for the tuition of the child or children attending a private or independent school contracting with PSAS. If the parents/guardians are divorced or separated, only the parent responsible for the tuition and any other adult residing in the household should fill out the form. If tuition is shared, each responsible party must complete a Student Aid Form (SAF) if financial aid is needed. Answer all questions for both parent(s), stepparent(s), or guardian(s) responsible for tuition for the dependent(s) listed in Section C. Do not leave any questions blank. If natural parents are divorced, separated or single, answer all questions in Section E. If natural parents are divorced/separated and remarried, list information for custodial parent and new spouse. If either parent answers “self-employed,” and has not filed a tax return, complete Section K. CALCULATIONS ARE BASED ON TOTAL HOUSEHOLD INCOME. STUDENT INFORMATION C List all dependent children residing in your household in order of oldest to youngest. If your dependents will be enrolled in any tuition charging school or agency next fall (including daycare, preschool, elementary school, high school, college, or trade school), list the name of the school,the city and state where the school is located. List the grade your child(ren) will enter next fall (20072008), and the amount of tuition charged per student per year. For all additional dependents, use a separate sheet. NOTE: The information regarding tuition charged per student assists PSAS in making the most equitable analysis of your ability to pay for private education. If you are unsure, please estimate. HOUSEHOLD INFORMATION D ITEM 1: Enter total number of individuals living in household. Include any college students claimed on the tax return. Do not include children who have moved out of the home. Include all family members dependent on and residing with parent listed in Section A. ITEM 2: Check the appropriate box indicating custodial parents’ marital status. If parents are divorced, separated or single, complete Section E. If dependent(s) parents are divorced or separated, or do not reside in the same household, the custodial parent must provide the information requested in Section E about the non-custodial parent. If the date of separation took place in the year 2007, PSAS will require copies of any tax returns filed jointly or independently by both parent(s)/guardian(s) for 2007. Be sure to estimate the income in Section F for 2008. ITEM 4: List the total amount of child support actually received by custodial parents listed in Sections A & B. If total received differs from court ordered amount, list only the total received. ITEM 6: Indicate who is responsible for tuition and what percentage for the dependents listed in Section C. TAXABLE INCOME F List all actual amounts for 2007 and estimated amounts for 2008. ITEM 1: Enter the total number of exemptions you claimed on your 2007 IRS Form 1040, 1040A, or 1040EZ. ITEM 2: Enter the total 2007 taxable income earned in wages, salaries and tips for parent/guardian/other listed in SECTION A. Attach all copies of 2007 W-2 forms and/or 2007 1099 forms from all employers. ITEM 3: Enter the total 2007 taxable income earned in wages, salaries and tips for parent/guardian/other listed in SECTION B. Attach all copies of 2007 W-2 forms and/or 2007 1099 forms from all employers. ITEM 4: Enter the total net income from business (attach Schedule C or C-EZ), all rents, royalties, partnerships (attach Schedule E), and all farm income or loss (attach Schedule F). If you have received income from any of these sources and are estimating your income for 2007, you must also fill out Section K of this application. (See 2007 1040 lines 12, 17 and 18, enter sum total.) ITEM 5: Enter the total of all other taxable income from interest, dividend income (attach Schedule B if over $400), taxable refunds, credits or offsets of state and local income taxes, alimony received, capital gain or loss (attach Schedule D). List all capital gain distributions not previously reported, total IRA distributions (if rolled- over, explain in Section L), pensions and annuities, unemployment compensation, taxable social security benefits, and any other taxable income. Attach copies of all Form 1099/1099R, and/or Form 1098 for Interest/Dividends, Pensions/Annuities or other misc. income. Attach copies of Social Security Income statements and Unemployment Compensation documentation for year-end 2007. (See 2007 1040 lines 8a, 9a-11, 13, 14, 15b, 16b, 19-21 or 1040A lines 8a-14b, enter sum total.) ITEM 6: Enter allowable adjustments to income, such as IRA payments, self- employment tax, self-employed health insurance deduction, Keogh retirement plan and self-employed SEP deductions, penalty on early savings withdrawals, and alimony paid. Add together to arrive at your total adjustments. DO NOT include your standard deduction or deduction amounts for each family member. (See 2007 1040 line 36 or 1040A line 20.) ITEM 7: Enter total adjusted gross income as reported on your IRS Form 1040, 1040A or 1040EZ. Attach all pages of the applicable tax form (1040, 1040A, 1040EZ) for documentation. (See 2007 1040 line 37 or 1040A line 21.) ITEM 8: Enter the Total Tax paid (not withheld) as reported on your IRS Form 1040, 1040A, or 1040EZ. (See 2007 1040 line 63 or 1040A line 37.) ITEM 9: Enter the total of any medical and dental expenses reported on Schedule A line 1 of your IRS Form 1040 (attach Schedule A). NON-TAXABLE INCOME G If you receive non-taxable income, you must list and provide documentation of the TOTAL YEARLY AMOUNTS received in 2007 for all recipients in the household for the following: Cash Assistance (TANF), Food Stamps, Social Security income, Student loans and/or grants (received for PARENT’s education), Housing Assistance (Section 8, HUD, etc.), Worker’s Compensation, Disability or Retirement. ITEM 10: Child support: Report total amount received for 2007 for all children in the household. ITEM 11: Cash Assistance (TANF): Report total amount received for 2007. ITEM 12: Food Stamps: Report total amount received for 2007. Do not combine with TANF. ITEM 13: Social Security benefits: Report the total non-taxable amount received in 2007 for all recipients in household. ITEM 14: Student loans and/or grants: Report the total amount received in 2007 for PARENT’S education. Do not list loans, grants or scholarships received for dependents in Section C. Identify how much of this income was used for household expenses in 2007. ITEM 15: Housing Assistance: Report the total amount received for 2007. Identify in Section L all sources of Housing Assistance (parsonage, government assistance, Section 8, HUD, family/friends or other sources), including monies received toward rental/mortgage payments and/or utilities. ITEM 16: Other non-taxable income: Report all additional non-taxable income received in 2007 including: Deductible IRA or Keogh payments; untaxed portions of pensions; tax exempt interest income; foreign income exclusion; Workers’ Compensation; veterans non-education benefits (Death Pension, Dependency and Indemnity Compensation, etc.); food and other living allowances paid to members of the military, clergy or others; cash support or any money paid on your behalf, including support from a non-custodial parent or any other person (do not include court ordered support here); or any other untaxed benefit or income not subject to taxation by any government (Refugee Assistance, VA Educational Work-Study, etc.). Identify source(s) in Section L. ITEM 17: Loans/Gifts received from friends or relatives: Report the total amount received in 2007. ITEM 18: Personal Savings/Investment Accounts: Report the total amount used in 2007 for household expenses. ITEM 19: Total non-taxable income for 2007: Add together Items 10-18. HOUSING INFORMATION H ITEM 20 and 21: If you rent your home or apartment, list your monthly rental or lease payment here, including amounts paid by household and other sources. ITEM 22a: Determine the present value of the family home and list it. Local real estate agents should be able to help you if you are unsure. ITEM 22b: Check with your lending institution and enter the amount still owed, including second mortgages. ASSETS AND INVESTMENTSI ITEM 23: List total of current balances in cash, savings, and checking accounts. Do not include IRAs or Keoghs. ITEM 24: List total current market value of money market funds, mutual funds, stocks, bonds, CDs or other securities. ITEM 25: List total current market value of all retirement funds, including IRA, Keogh, 401K, and SEP plans or other retirement accounts. ITEM 26: Answer Items 26a and 26b for any and all investment real estate (not including the family’s primary residence), if applicable. Second homes, rental properties, and land contracts should be included. ITEM 27: If you own a business, check the Yes box and answer Items 27a and 27b. If you have not filed your 2007 tax return, complete Section K of this application. ITEM 28: If you own a farm, check the Yes box and answer Items 28a and 28b. If you have not filed your 2007 tax return, complete Section K of this application. UNUSUAL CIRCUMSTANCES J Check any and all items that apply to your situation. If your circumstances require explanation beyond the scope of this application, please notify the school to which you are applying. Do not include a letter of explanation with this application. BUSINESS INCOMEK Provide 2007 Business Income Estimates if you have not filed your 2007 Tax Return. ITEM 1: List estimated total GROSS taxable business income for 2007. ITEM 2: List estimated total NET taxable business income/loss for 2007. ITEM 3: List the total amount paid by business in 2007 for home rent or mortgage. ITEM 4: List the total amount paid by business in 2007 for personal automobile. ITEM 5: List the total amount of personal expenses paid by business in 2007 that do not fall into one of the categories above. ITEM 6: List total amount of estimated rental income received in 2007. If providing income estimates for more than one business, corporation or farm (Schedule C, Schedule E and/or Schedule F) please list information for each business, corporation or farm separately. Use additional sheet or Section L, if necessary. EXPLANATION L If any specific question requires clarification, write a brief explanation in this space. If your circumstances require explanation beyond the scope of this application, please notify the school to which you are applying. PARENTS’ CERTIFICATION, AUTHORIZATION, AND DOCUMENTATION CHECKLIST M You must sign the form in this section. Your signature authorizes PSAS to release the form and attachments to the contracting schools indicated in Section C. By signing the form, you also certify that the information submitted is correct. This application CANNOT be considered complete without the appropriate signature(s) and the appropriate documentation. REQUIRED DOCUMENTATION If you have filed your 2007 IRS Form 1040: You must submit photocopies of all pages of your 2007 Federal Tax Return Form 1040, 1040A or 1040EZ (as filed with the IRS, with all Schedules, 2007 W-2 Forms, 2007 1099/1099R, or 1098 Forms) for any wage-earning adult residing with the applicant(s). Do not include your State tax return unless requested. If you have not filed your 2007 IRS Form 1040: You must submit photocopies of all 2007 W-2 Forms, 2007 1099/1099R, or 1098 Forms for any wage-earning adult residing with the applicant(s), and photocopies of all pages of your most recent Federal Tax Return Form 1040, 1040A or 1040EZ (as filed with the IRS, with all Schedules). If this application is submitted after April 15, 2008, you must provide a copy of the 2007 Extension for Filing Request, as approved by the IRS. If you are an Independent Contractor or self-employed and have not filed your 2007 IRS Form 1040: You must complete Section K and submit photocopies of all pages of your most recent Federal Tax Return Form 1040, 1040A or 1040EZ (as filed with the IRS, with all Schedules, 2007 W-2 Forms, 2007 1099/1099R, or 1098 Forms) for any wage-earning adult residing with the applicant(s). If this application is submitted after April 15, 2008, you must provide a copy of the 2007 Extension for Filing Request, as approved by the IRS. If you receive non-taxable income: You must submit photocopies of your 2007 YEAR-END (01/01/07 - 12/31/07) Cash Assistance documentation (TANF, etc.), Food Stamp documentation, Housing Assistance documentation, Student loan and/or grant documentation (for PARENT’s education), Social Security Income statements, showing the TOTAL AMOUNT received in 2007 for ALL members of the household. If you list any total for line 16, you must identify source(s) in Section L. Queens School Codes (List School Codes in Section C.) 6038.... 5979.... 5982.... 5962.... 5969.... 5954.... 6026.... 6027.... 5989.... 6028.... 6029.... 6033.... 5995.... 5998.... 5964.... 5999.... 6037.... 6000.... 5967.... 6005.... 5997.... 6038.... 6001.... 6039.... 6004.... 6009.... 6044.... 6045.... 6010.... 6030.... 5974.... 5944.... 6017.... Blessed Sacrament (Our Lady of the) - Bayside Blessed Sacrament School - Jackson Heights Corpus Christi School - Woodside Divine Mercy Catholic Acad/Nativity of BVM - 92nd St. Rockaway Blvd. Divine Mercy Catholic Acad/St. Stan, Bishop Matyr - 101st Ave. Holy Child Jesus School - Richmond Hill Holy Family School - Flushing Holy Trinity School - Whitestone Immaculate Conception School - Astoria Immaculate Conception School - Jamaica Incarnation School - Queens Village Mary's Nativity School - Flushing Most Precious Blood School - Long Island City Our Lady of Fatima School - Jackson Heights Our Lady of Grace School - Howard Beach Our Lady of Hope School - Middle Village Our Lady of Lourdes School - Queens Village Our Lady of Mercy School - Forest Hills Our Lady of Perpetual Help School - S. Ozone Park Our Lady of Sorrows School - Corona Our Lady of the Angelus School - Rego Park Our Lady of the Blessed Sacrament - Bayside Our Lady of the Miraculous Medal - Ridgewood Our Lady of the Snows - North Floral Park Our Lady Queen of Martyrs - Forest Hills Resurrection-Ascension - Rego Park Sacred Heart School - Bayside Sacred Heart School - Cambria Heights Sacred Heart School - East Glendale SS. Joachim and Anne - Queens Village St. Adalbert School - Elmhurst St. Aloysius School - Ridgewood St. Anastasia - Douglaston 6018.... 6019.... 5945.... 5978.... 5946.... 5949.... 6020.... 6021.... 5950.... 6023.... 5952.... 5983.... 5984.... 6025.... 5953.... 5990.... 5991.... 6031.... 5992.... 6032.... 5993.... 5959.... 5960.... 5994.... 6034.... 6035.... 6036.... 6006.... 6008.... 6043.... 5968.... 6011.... 6013.... 5971.... 5972.... St. Andrew Avellino - Flushing St. Ann School - Flushing St. Anthony of Padua - S. Ozone Park St. Bartholomew - Elmhurst St. Benedict Joseph Labre - Richmond Hill St. Camillus School - Rockaway Park St. Catherine of Sienna - St. Albans St. Clare School - Rosedale St. Elizabeth School - Ozone Park St. Fidelis School - College Point St. Francis De Sales - Belle Harbor St. Francis of Assisi - Astoria St. Gabriel School - East Elmhurst St. Gregory the Great - Bellerose St. Helen School - Howard Beach St. Joan of Arc - Jackson Heights St. Joseph School - Astoria St. Kevin School - Flushing St. Leo School - Corona St. Luke School - Whitestone St. Margaret School - Middle Village St. Mary Gate of Heaven - Ozone Park St. Mary Star of the Sea - Far Rockaway St. Matthias School - Ridgewood St. Mel School - Flushing St. Michael School - Flushing St. Nicholas of Tolentine - Jamaica St. Pancras School - Glendale St. Raphael School - Long Island City St. Robert Bellarmine - Bayside St. Rose of Lima - Rockaway Beach St. Sebastian - Woodside St. Stanislaus Kostka - Maspeth St. Teresa of Avila - S. Ozone Park St. Thomas the Apostle - Woodhaven Brooklyn School Codes (List School Codes in Section C.) 5947.... 6055.... 6046.... 5912.... 5913.... 5935.... 6056.... 5921.... 6002.... 6050.... 5916.... 5917.... 5918.... 5919.... 5955.... 5966.... 5957.... 5938.... 5900.... 5902.... 5903.... 5904.... 5926.... 5948.... 5927.... Blessed Sacrament - Euclid Ave. Flatbush Catholic Academy - Church Ave. Good Shepherd - Brown St. Holy Name School - Prospect Park W Immaculate Heart of Mary - Fort Hamilton Pkwy. Mary Queen of Heaven - East 57 St. Midwood Catholic Academy - East 29 St. Most Precious Blood - 27th Ave. Northside Catholic Academy/Our Lady Mt. Carmel - Withers St. Northside Catholic Academy/St. Vincent dePaul - North 7 St. Our Lady of Angels - 74th St. Our Lady of Grace - Avenue W Our Lady of Guadalupe - 73rd St. Our Lady of Perpetual Help - Sixth Ave. Our Lady of Trust @ Holy Family - Flatlands Ave. Our Lady of Trust @ Our Lady of Miracles - East 87 St. Our Lady of Trust @ St. Jude - Canarsie Rd. Queen of All Saints - Vanderbilt Ave. St. Agatha School - 48th St. St. Anselm School - 83rd St. St. Athanasius School - Bay Pkwy. St. Bernadette School - 83rd St St. Bernard School - East 69 St. St. Brigid School - Grove St. St. Catherine of Genoa - Albany Ave. 5981.... 5928.... 5958.... 5907.... 5951.... 6047.... 5914.... 5929.... 5910.... 5930.... 5933.... 5934.... 6054.... 6048.... 5914.... 5961.... 5966.... 5920.... 6049.... 5923.... 6012.... 5970.... 5941.... 5943.... 5925.... St. Cecilia School - Monitor St. St. Edmund School - Avenue T St. Elizabeth Seton - Knickerbocker Ave. St. Ephrem School - Fort Hamilton St. Fortunata School - Linden Blvd. St. Frances Cabrini - Suydam St. St. Frances Cabrini Acad/Mary Mother of Jesus -23rd Ave. St. Francis of Assisi - Lincoln Rd. St. Francis Xavier - President St. St. Gregory the Great - St. John's Place St. Jerome School - East 29 St. St. John the Baptist - Lewis Ave. Sts. Joseph and Dominic Academy - Montrose Ave. St. Mark School - East 19 St. St. Mary Mother of Jesus - 23rd Ave. St. Michael School - Jerome St. St. Nicholas School - Powers St. St. Patrick School - 97th St. St. Rita School - Shepherd Ave. St. Saviour School - Eighth Ave. St. Stanislaus Kostka - Newell St. St. Sylvester School - Grant Ave. St. Therese of Lisieux - Avenue D St. Vincent Ferrer - Brooklyn Ave. Visitation Academy - Ridge Blvd. DIOCESE OF BROOKLYN AND QUEENS - PARISH CODE LIST 54004 . . . . All Saints 54008 . . . . American Martyrs 54014 . . . . Annunciation 54018 . . . . Ascencion of Elmhurst 55109 . . . . Assumption of the BVM 53030 . . . . Blessed Sacrament (Brooklyn) 54031 . . . . Blessed Sacrament (Jackson Hts) 53230 . . . . Blessed Trinity 54032 . . . . BVM Help of Christians 55044 . . . . Christ the King 54048 . . . . Corpus Christi 52072 . . . . Good Shepherd 51075 . . . . Guardian Angel 53077 . . . . Holy Child Jesus 52078 . . . . Holy Cross (Brooklyn) 54079 . . . . Holy Cross (Maspeth) 53081 . . . . Holy Family (Brooklyn East) 54082 . . . . Holy Family (Brooklyn West) 51080 . . . . Holy Family (Park Slope) 55083 . . . . Holy Family (Flushing) 52085 . . . . Holy Innocents 51086 . . . . Holy Name 51084 . . . . Holy Spirit 55089 . . . . Holy Trinity 55092 . . . . Immaculate Conception (Jamaica) 54093 . . . . Immaculate Conception (LIC) 51094 . . . . Immaculate Heart of Mary 55095 . . . . Incarnation 53101 . . . . Mary, Mother of the Church 52209 . . . . Mary of Nazareth 52128 . . . . Mary Queen of Heaven 55122 . . . . Mary’s Nativity 54088 . . . . Most Holy Trinity - St. Mary 51193 . . . . Most Precious Blood (Brooklyn) 54139 . . . . Most Precious Blood (LIC) 53140 . . . . Nativity of the BVM 52155 . . . . Our Lady Help of Christians 51144 . . . . Our Lady of Angels 54145 . . . . Our Lady of Consolation 51149 . . . . Our Lady of Czestochowa-St. Casmir 54150 . . . . Our Lady of Fatima 52151 . . . . Our Lady of Good Counsel 51152 . . . . Our Lady of Grace (Brooklyn) 53153 . . . . Our Lady of Grace (Howard Beach) 51154 . . . . Our Lady of Guadalupe 54156 . . . . Our Lady of Hope 53158 . . . . Our Lady of Loreto 55160 . . . . Our Lady of Lourdes (QV) 53161 . . . . Our Lady of Mercy (Brooklyn) 54162 . . . . Our Lady of Mercy (Forest Hills) 53163 . . . . Our Lady of Miracles 54166 . . . . Our Lady of Mount Carmel (Brooklyn) 54167 . . . . Our Lady of Mount Carmel (LIC) 51168 . . . . Our Lady of Peace 51169 . . . . Our Lady of Perpetual Help (Brooklyn) 53170 . . . . Our Lady of Perpetual Help (Richmond Hill) 52173 . . . . Our Lady of Refuge 51177 . . . . Our Lady of Solace 54145 . . . . Our Lady of the Angelus 55165 . . . . Our Lady of the Blessed Sacrament 53146 . . . . Our Lady of the Cenacle 54164 . . . . Our Lady of the Miraculous Medal 53171 . . . . Our Lady of the Presentation 54174 . . . . Our Lady of the Rosary of Pompeii 55176 . . . . Our Lady of the Snows 54178 . . . . Our Lady of Sorrows 54172 . . . . Our Lady Queen of Martyrs 55194 . . . . Presentation of the BVM 52195 . . . . Queen of All Saints 54196 . . . . Queen of Angels 55197 . . . . Queen of Peace 52200 . . . . Resurrection 54021 . . . . Resurrection-Ascencsion 52210 . . . . Sacred Heart (Bayside) 55211 . . . . Sacred Heart (Cambria Heights) 54212 . . . . Sacred Heart (East Glendale) 51214 . . . . Sacred Heart-St. Stephen 54049 . . . . SS. Cyril and Methodius 55098 . . . . SS. Joachim and Anne 54190 . . . . SS. Peter and Paul 51217 . . . . SS. Simon and Jude 54001 . . . . St. Adalbert 51002 . . . . St. Agatha 53005 . . . . St. Aloysius 55009 . . . . St. Anastasia 55011 . . . . St. Andrew Avellino 51010 . . . . St. Andrew the Apostle 55013 . . . . St. Ann 51015 . . . . St. Anselm 53017 . . . . St. Anthony of Padua 54016 . . . . St. Anthony-St. Alphonsus 51020 . . . . St. Athanasius 51021 . . . . St. Augustine 53022 . . . . St. Barbara 54023 . . . . St. Bartholomew 53025 . . . . St. Benedict Joseph Labre 55026 . . . . St. Benedict the Moor 51027 . . . . St. Bernadette 52028 . . . . St. Bernard 55033 . . . . St. Bonaventure 52034 . . . . St. Boniface 51035 . . . . St. Brendan 53036 . . . . St. Brigid 53037 . . . . St. Camillus 51039 . . . . St. Catharine of Alexandria 52040 . . . . St. Catharine of Genoa 55041 . . . . St. Catharine of Siena 54042 . . . . St. Cecilia 51043 . . . . St. Charles Borromeo 55045 . . . . St. Clare 55046 . . . . St. Clement Pope 52047 . . . . St. Columba 51050 . . . . St. Dominic 52051 . . . . St. Edmund 53052 . . . . St. Elizabeth 51053 . . . . St. Ephrem 55055 . . . . St. Fidelis 51056 . . . . St. Finbar 53057 . . . . St. Fortunata 51059 . . . . St. Frances Cabrini 51060 . . . . St. Frances de Chantal 53061 . . . . St. Francis de Sales 54063 . . . . St. Francis of Assisi 52062 . . . . St. Francis of Assisi-St. Blaise (Brooklyn) 54064 . . . . St. Francis of Paola 51065 . . . . St. Francis Xavier 54067 . . . . St. Gabriel 55070 . . . . St. Gerald Majella 53071 . . . . St. Gertrude 55074 . . . . St. Gregory the Great (Bellerose) 52073 . . . . St. Gregory the Great (Brooklyn) 53076 . . . . St. Helen 52090 . . . . St. Ignatius 52096 . . . . St. James Cathedral 52097 . . . . St. Jerome 54099 . . . . St. Joan of Arc 52100 . . . . St. John the Baptist 51102 . . . . St. John the Evangelist 55103 . . . . St. John Vianney 55108 . . . . St. Josephat 52104 . . . . St. Joseph (Brooklyn) 55106 . . . . St. Joseph (Jamaica) 54105 . . . . St. Joseph (LIC) 63107 . . . . St. Joseph Patron of the Universal Church 53109 . . . . St. Jude 55110 . . . . St. Kevin 53111 . . . . St. Laurence 54112 . . . . St. Leo 52182 . . . . St. Lucy - St. Patrick 55115 . . . . St. Luke 54117 . . . . St. Margaret 52118 . . . . St. Margaret Mary (Brooklyn) 52120 . . . . St. Mark 52179 . . . . St. Martin de Porres 53121 . . . . St. Martin of Tours 54123 . . . . St. Mary 53125 . . . . St. Mary Gate of Heaven 55126 . . . . St. Mary Magdalene 51127 . . . . St. Mary Mother of Jesus 51129 . . . . St. Mary Star of the Sea (Brooklyn) 53130 . . . . St. Mary Star of the Sea (Far Rockaway) 52131 . . . . St. Matthew 54132 . . . . St. Matthias 55133 . . . . St. Mel 55136 . . . . St. Michael (Flushing) 53135 . . . . St. Michael (ENY) 53116 . . . . St. Michael - St. Malachy 54142 . . . . St. Nicholas 55413 . . . . St. Nicholas of Tolentine 54180 . . . . St. Pancras 55181 . . . . St. Pascal 51183 . . . . St. Patrick (Brooklyn) 54184 . . . . St. Patrick (LIC) 51003 . . . . St. Paul & St. Agnes 54240 . . . . St. Paul Chong Ha-Sang Chapel 54186 . . . . St. Paul the Apostle 55191 . . . . St. Pius V 55192 . . . . St. Pius X 54198 . . . . St. Raphael 53202 . . . . St. Rita (Brooklyn) 54203 . . . . St. Rita (LIC) 55204 . . . . St. Robert Bellarmine 51205 . . . . St. Rocco 51239 . . . . St. Rosalia-Regina Pacis 52207 . . . . St. Rose of Lima (Brooklyn) 53208 . . . . St. Rose of Lima (Rockaway Beach) 51215 . . . . St. Saviour 54216 . . . . St. Sebastian 53218 . . . . St. Stanislaus Bishop and Martyr 54219 . . . . St. Stanislaus Kostka (Brooklyn) 54220 . . . . St. Stanislaus Kostka (Maspeth) 53222 . . . . St. Sylvester 54224 . . . . St. Teresa 52223 . . . . St. Teresa of Avila (Brooklyn) 53225 . . . . St. Teresa of Avila (South Ozone Park) 52226 . . . . St. Therese of Lisieux 52229 . . . . St. Thomas Aquinas (Flatlands) 51228 . . . . St. Thomas Aquinas (Park Slope) 53227 . . . . St. Thomas the Apostle 52234 . . . . St. Vincent Ferrer 53236 . . . . St. Virgilus 54231 . . . . Transfiguration (Brooklyn) 54232 . . . . Transfiguration (Maspeth) 51237 . . . . Visitation of the BVM LIST PARISH CODE IN SECTIONS A AND B Form 107 Living Expenses/No Tax Return TR 2007 PRIVATE SCHOOL AID SERVICE LIVING EXPENSES EXCEED INCOME/NO INCOME TAX RETURN FILED 2007 © Private School Aid Service Parent/Guardian Name: _______________________________ SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State: ____ Based on the information provided with your Student Aid Form, PSAS is requesting additional information. The income provided is not sufficient to cover the expenses recorded on the application. Please complete this additional worksheet and provide all documentation and additional income amounts/sources used by you and your family during the year 2007. THIS FORM IS TO BE COMPLETED BY: Name: ____________________________________________ SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ the second parent/guardian or other adult listed inIf you FILED a 2007 tax return, complete the following: I was required to file a 2007 Federal Income Tax Return form 1040, 1040A, or 1040EZ. _____ I have attached all required tax returns and schedules, etc. and will return them to PSAS with this worksheet. the second parent/guardian or other adult listed inIf you DID NOT FILE a 2007 tax return complete the following: I was NOT required to file a 2007 Federal Income Tax Return. _____ In place of a tax return, I have completed this notice and attached all income documentation and will return them to PSAS with this worksheet. 1. I did not file a tax return for the following reason (check one): • Received no taxable income. • Taxable Income received was less than the amount required for filing with the IRS • Other (explain) _____________________________________________________ 2. The TOTAL household income from all residents (taxable and/or nontaxable) for the entire 2007 year: • Wages* $ ____________________ • Permanent Fund Dividend* $ ____________________ • Unemployment Benefits* $ ____________________ • Child Support $ ____________________ • Public assistance (cash assistance, food stamps, etc.)* $ ____________________ • Housing assistance (HUD, Section 8, parsonage, etc.)* $ ____________________ • Social Security Benefits (for all members of household)* $ ____________________ • Student loans, grants, scholarships (FOR PARENT)* $ ____________________ • Workers Compensation or Disability Benefits* $ ____________________ • Gifts/Loans from family members/friends $ ____________________ • Use of personal savings, investment accounts, home equity $ ____________________ • Loans from banks, credit unions or other institutions $ ____________________ • Increase in credit card debt $ ____________________ • Amount of Home Equity used to pay living expenses $ ____________________ • Other (explain) ____________________________________ $ ____________________ *You must provide year-end (01/01/07-12/31/07) documentation of these items. Additional Explanation: I DECLARE that the information provided on this form is true, correct, and complete to the best of my knowledge. Parent/Guardian Signature Date PLEASE RETURN THIS FORM AND ANY OTHER SUPPORTING DOCUMENTATION IMMEDIATELY TO: Private School Aid Service / 909 Canterbury Road Suite P / Westlake, Ohio 44145 You may obtain a copy of your Federal Tax Return transcript (request a Full Transcript)or notification that you did not file by contacting the IRS at 1-800-829-1040 or by visiting www.irs.gov.