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U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-6053 (12-05)

DOC. NO.

Coast Guard Foundation Scholarship Financial Aid Form
Date:

CG-1112 Only:

Applicant Name :

Please complete this form and submit it with your application packet. You are providing self-certification of your financial need. Do not submit pay stubs, tax forms, or your Free Application for Federal Student Aid (FAFSA) form. You may submit a written statement to further define your financial need. List your anticipated college cost for the year below:

Tuition $ Transportation $

Housing $

Lab Fees $ Personal expense $

Books $ Other $

Total college cost per year: $ · · · · · · · · · · How much money have you saved for college? Have you applied for o ther scholarships? If yes, how much have you been awarded? Have you applied for college grants? Yes No Yes No Yes No No Have you received approval for college grants? If yes, how much have you been awarded? Have you applied for a college loan? Yes Yes No Yes No

Have you received any scholarships for school?

Are you applying for money to complete undergraduate studies? If no, please explain:

Student/Sponsor Certification: We certify that, to the best of our knowledge, all responses are true and factual, and the sponsor, as well as the applicant, has reviewed the scholarship eligibility requirements. We verify the applicant is unmarried and has not reached the age of twenty-three (23) on this day. We also agree, if the applicant is selected as a scholarship recipient, applicant, parent and sponsor name, along with sponsor duty location will be used for purposes of news and publicity of the Coast Guard Foundation Scholarship Program by Commandant (CG-1112) and the Coast Guard Foundation for current and future promotions of the scholarship program. Signature of Applicant: Print name: Signature of Sponsor: Print name: 5 U.S.C. 552(a) Privacy Act
a. AUTHORITY: 5 U.S.C. § 301 Departmental Regulations b. PURPOSE: To collect information for the purpose of processing requests for consideration for award of a Coast Guard Foundation Scholarship. c. ROUTINE USES: Used in the performance of official duties related to the processing of scholarship documents. Viewed by the selection panel and Coat Guard Foundation staff. d. DISCLOSURE: Voluntary; however failing to provide the information may result in disqualification from consideration for award of a Coast Guard Foundation scholarship.

Date:

Date:

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-6053 (Rev. 12-05)

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