Scholarship Application

Type of Scholarship

Name

Phone

Email Address

Address

Employer Name (if any):

Employer Address:

Monthly net income from work (after taxes) $

Monthly public assistance checks $

Monthly unemployment compensation $

Any other monthly or annual income $

Total Net Income $

How many adults are supported by this income:

How many children are supported by this income:

Monthly rent or mortgage $

How much do you think you could afford to pay each month for a membership?

Please include a short paragraph sharing experiences and insights about your need for and interest in the Blue Lotus Scholarship.

Agreement Agreement I swear under penalty of perjury that all information which I have provided above and in attached documents is accurate and complete. I agree to notify Blue Lotus Community Fund if there is any change in my income or expenses which would affect my eligibility for scholarship within 5 days of those changes.

DOCUMENTS REQUIRED:

Blue Lotus Community Fund requires written verification of your monthly income such as pay stubs, income tax return, evidence of your receipt of government or other financial assistance, bank account statements, credit reports, and other documents that will help establish your financial situation.