APPLICATION FORM HERITAGE COMBINED SCHOLARSHIP INSTRUCTIONS FOR COMPLETING FORM CONTINUE OUR

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1 COMBINED SCHOLARSHIP FORM INSTRUCTIONS FOR COMPLETING FORM Please refer to the Heritage Fund s Education Brochure for information about how to apply for all the scholarships administered by the Heritage Fund. This application should be used to apply for 51 of the scholarships administered by the Heritage Fund. The scholarships using this application are listed below. Other scholarships administered by the Heritage Fund, but not listed below, require a separate application. Please check the box by the scholarship(s) for which you are applying. Analytical Engineering, Inc. (AEI) Paul Arnett Memorial Bartholomew County REMC J. Howard Beam Memorial Mary E. Behler Memorial Todd & Julie Bergman Cliff Blake Memorial Abby Brinkman Frank Burbrink Memorial 4-H Abigail Carson Memorial Lucien J. & Maryann J. Chadwick and Sam & Edith Shanks Memorial Class of 1948 to Further the Teaching Profession in the Name of Alta Redmond Karen Ann Coffman Memorial Nursing Columbus Business & Professional Women s Columbus Herb Society Columbus Rotary in Honor of Judson S. Erne Charles M. & Frances W. Condit Nursing Education Homer & Mildred Crank * J. Albert Finkel and Irma Jane Finkel Louis & Kathy M. Giovanini Myron Glick Memorial Becky S. Green Memorial Bill & Jody Harter Mary Ann Heise Memorial Earl E. & Mildred L. Bless Hudson for Education Marvin Johnson Jones Sisters LHP Lacey Family The Reverend Dr. William R. Laws Memorial Corilla B. Lentz Doug Leonard Healthcare Occupations Bob Marshall - Bob Gordon Memorial for Print Journalism Mayor s Government Julie M. McKinney Memorial John McLachlan Soccer Anthony Moravec Bob & Marcy Oswald Engineering Andrew Parker Memorial Kirby & Caroline Risk Michael R. Rogers Marguerite Burns Rust Marguerite Burns Rust for Veterinary Studies Charles D. Shepherd Memorial Laura Showalter Memorial Music * Paul and Prudence Steinbarger Memorial Barbara W. Stewart Jennifer Strietelmeier Toyota Industrial Equipment Mfg., Inc. Helmut O. von Buchler & Hartmut K. von Buchler 4-H Memorial John & Geneva Wickens * requires additional essay in order to be considered. Due to fluctuating market conditions some scholarships may not be available in Please check the Heritage Fund website for updated information on each of these scholarships. The essay for the Heritage Fund Combined Applications asks: Tell us of a life experience that has impacted you significantly. Describe how that experience has influenced where you are today and how you believe it will shape your future. The essay should be one to three pages, typed in 12 point font and double-spaced. Please write or type the last four digits of your Social Security number in the upper right hand corner of all pages to identify your essay as well as the topic of your essay. DO NOT write or type your name on the essay. Please submit the most recent copy of your official high school or college transcript or GED Certificate with this application. New for 2009: Heritage Fund will only accept online transcripts submitted through the Docufide web system. Bartholomew County s public high schools guidance offices are set up for this system. (Check your school to see if it has Docufide capabilities.) When using your Docufide account to have a transcript sent, the Heritage Fund is listed as an institution. If your transcript is not submitted through Docufide, the Heritage Fund will only accept official transcripts that are in a sealed envelope. Copies or other online transcripts will not be accepted. One character recommendation is required with this application. Please use the enclosed recommendation form. It should be completed by a classroom teacher, counselor, supervisor or other professional, who is not a relative. The deadline for submitting completed applications to the Heritage Fund is 4:00 p.m., February 20, This does not mean postmarked. The completed form can either be delivered to the Heritage Fund office at 538 Franklin Street, Columbus, or mailed to P.O. Box 1547, Columbus, Indiana

2 Please read and complete the entire application. Please type or print neatly with a black pen. All items must be legible and all information must be included. Student Information: Name: Address: Last Four Digits S.S.#: City/State/Zip: Male Female Telephone: Cell phone: D.O.B.: Are you a first generation college student? Yes Parent or Guardian Information: No Name of Father/Guardian: Occupation: Name of Mother/Guardian: Occupation: Address: (If different than above) City/State/Zip: Daytime Telephone: With whom do you reside: Parent s current marital status: Single Married Separated Divorced Widowed Please submit completed application to: Heritage Fund - the Community Foundation of Bartholomew County 538 Franklin Street P.O. Box 1547 Columbus, Indiana Certification: In submitting this application, I certify that the information provided is complete and accurate to the best of my knowledge. Falsification of information may result in termination of any scholarship granted by the Heritage Fund. Signature: Date: DEADLINE DATE: FEBRUARY 20, 2009, 4:00 P.M.

3 Last Four Digits Social Security No. Academic/Career Information: To be completed by graduating high school seniors: High School: Graduation Date: Class Rank: Out of: GPA: ACT Composite Score: SAT Score: Critical Reading: Math: Total of Critical Reading & Math: Name of university, college or technical school you plan to attend, in order of preference: Accepted: Yes No School Accepted: Yes No School Accepted: Yes No School Location (City/St) Location (City/St) Location (City/St) Intended Major: Do you anticipate attending college full or part-time? Full-time Part-time To be completed by applicants currently attending college or returning to college: High School Attended: Graduation Date: Current School: Expected Graduation Date: Major: Intended Degree: Current GPA: Hours required to complete degree: School extracurricular activities in which you have participated, include years: (9, 10, 11, 12 or college year) Community organizations and activities in which you have been involved, include years: (9, 10, 11, 12 or college year) Awards, honors and achievements, include year(s) received: (9, 10, 11, 12 or college year)

4 Last Four Digits Social Security No. Employment Experience: (begin with most recent job) Employer: Average Hours Per Week: Position Held: Dates: From To: Duties: Employer: Average Hours Per Week: Position Held: Dates: From To: Duties: How do you plan to finance your education? Do you plan to work while attending school? Have you been awarded any scholarships for tuition, required fees or books? Yes If yes, from where and please list if it is a one-time scholarship or a multi-year scholarship and the amount. No Name of Awarding Institution One-time or multi-year Amount Please explain any special family or personal situations that the Selection Committee should know about in reviewing your scholarship needs.

5 Last Four Digits Social Security No. Complete the following information that pertains to any of the scholarships for which you are applying. Mary E. Behler Memorial This applicant is an active member of: Parish. Signature of Parish Priest or Parish Youth Minister: Columbus Rotary in Honor of Judson Erne Name of school-sponsored service organization of which you are a member: J. Albert Finkel and Irma Jane Finkel Are you currently a student in Purdue s School of Agriculture or have you been accepted into the program? Yes No Additional essay required: What led you to choose the field of agriculture and describe your anticipated role in this field in 10 years (typed in 12pt font, 1 page). Marvin Johnson Please list the name of the trucking company with which you or a family member is associated and your or his/her job position: Bob Marshall - Bob Gordon Memorial for Print Journalism What are your educational goals (advanced programs or degrees) and how will these goals relate to the field of journalism? Laura Showalter Memorial Music Musical Background: Please list musical performances - school or other: In what music programs are you currently participating? Paul and Prudence Steinbarger Memorial Have you been accepted to Indiana University? Yes No If yes, state campus location: Additional essay required: Please provide essay on career goals and how this scholarship might help in attainment of these goals (typed in 12pt font, 1 page).

6 FINANCIAL FORM Last Four Digits Social Security No. Please read and follow all directions carefully. All information will remain strictly confidential. If a question does not apply, please indicate with a N/A. Do not leave any space blank. Please use figures from your and/or your parents 2008 Federal tax return. If you are unable to provide your 2008 tax information, please use your 2007 tax return to estimate 2008 financials. Please indicate any financial changes that would affect your status this year. Information left blank may affect the outcome of your application. The Applicant column is for the applicant s tax and income information. The Parent A column is for parents who are married and file a joint tax return. If your parents are separated or divorced the Parent A column is to be completed by the parent with whom you reside. The Parent B column should be completed by your other parent. If you are legally independent from your parents, complete only the applicant information. If you feel you have special circumstances that significantly impact your finances that will not be reflected in this form, please contact the Manager at Heritage Fund. Income Information: Applicant Parent A Parent B 2008 Adjusted Gross Income (Form 1040, Line 37) $ $ $ 2008 U.S. Income Tax Paid (Form 1040, Line 72) $ $ $ 2008 Applicant s Income from Work $ 2008 Father s Income from Work (From W-2) $ $ 2008 Mother s Income from Work (From W-2) $ $ Number of Dependents Claimed on 2008 Tax Return Asset Information (all values as of Sept. 30, 2008) Cash, savings and checking accounts $ $ $ Net worth of investments value** (net worth=current $ $ $ value minus debt) ** Investments include real estate, trust funds, money market funds, mutual funds, certificates of deposit, stocks, stock options, bonds, other securities, educational IRAs, college savings plans, installment and land sale contracts (including mortgages held), commodities, etc. Exclude the home you live in, life insurance and retirement plans. Number in household (include applicant, siblings, parents) Number of college students enrolled at least half-time in the Fall of 2009 (include applicant) Highest school your father completed: Middle School High School College or beyond Technical/Vocational Unknown Highest school your mother completed: Middle School High School College or beyond Technical/Vocational Unknown

7 RECOMMENDATION FORM Please remove this section. This section to be completed by a classroom teacher, counselor, advisor, supervisor or other professional. STUDENT S NAME: To be completed by a classroom teacher, counselor, advisor, supervisor or other professional, who is not a relative, with whom student has a working relationship. Please return this recommendation form in a sealed envelope by February 13, 2009 to the student, or by 4:00 p.m. February 20, 2009 to Heritage Fund. Failure to return this form by these deadlines will jeopardize the applicant s opportunity to be considered for this scholarship. The information for section B must be typewritten in no smaller than a 10 pt. typeface or legibly hand-written in black ink. It is also acceptable to cut and paste a Word document if desired. However, the recommendation must fit in the space below. In fairness to all applicants, attachments should not be included and will not be considered. Relationship to Applicant: Period of time you have known the applicant: How well have you known the applicant? Very Well Fairly Well Limited Contact A. Please rate the applicant in the following categories: Excellent Very Good Average Below Avg. Poor Unknown Work Habits Ability to set realistic goals Integrity Perseverance Self-Concept Accepts responsibility Cooperation Respectfulness B. In your opinion, what distinguishes this student from his/her peers? Form completed by: Phone #: Signature: Title: Date:

8 A few happy faces from the 2008 Donor/Scholar Reception held last May.