BERYL IVEY CONTINUING ENTRANCE AWARD

2012-2013 Deadline: February 14, 2012 To be completed in addition to the National Scholarship Application This application is for students applying to the National Scholarship Program and would like to be considered for the Beryl Ivey Continuing Entrance Award.
Applicants Information
Last Name Marital Status (circle one) Married/common-law Single First Name Birth Date (dd/mm/yyyy) UWO Student # or OUAC# School Name

Family Information (Required for all applicants)

Number of immediate family members who live in your Parental home, including yourself: Number of immediate family members who live in your Parental home attending postsecondary, including yourself:

2010 REQUIRED
Mothers Occupation:_______________ Self Employed: Yes No s Mothers Gross Income (Line 150 of Income Tax Return) : Fathers Occupation:________________ Self Employed: Yes No Fathers Gross Income (Line 150 of Income Tax Return) : Spouses Occupation:_________________ Self Employed: Yes No Spouses Gross Income (Line 150 of Income Tax Return) :

Mothers EI Premiums (Line 312 of Income Tax Return): Mothers CPP Contributions (Line 308 & 310 of Income Tax Return):

Fathers EI Premiums (Line 312 of Income Tax Return): Fathers CPP Contributions (Line 308 & 310 of Income Tax Return):

Spouses EI Premiums (Line 312 of Income Tax Return): Spouses CPP Contributions (Line 308 & 310 of Income Tax Return):

Mothers Income Tax Payable (Line 435 of Income Tax Return):

Fathers Income Tax Payable (Line 435 of Income Tax Return):

Spouses Income Tax Payable (Line 435 of Income Tax Return):

Parental/Spousal Contribution for 2012/2013 Academic Year $

Other Expected Resources $

2009 REQUIRED
Mothers Occupation: Self Employed: Yes No Mothers Gross Income (Line 150 of Income Tax Return) : Fathers Occupation: Self Employed: Yes No Fathers Gross Income (Line 150 of Income Tax Return) : Spouses Occupation: Self Employed: Yes No Spouses Gross Income (Line 150 of Income Tax Return) :

Mothers EI Premiums (Line 312 of Income Tax Return): Mothers CPP Contributions (Line 308 & 310 of Income Tax Return):

Fathers EI Premiums (Line 312 of Income Tax Return): Fathers CPP Contributions (Line 308 & 310 of Income Tax Return):

Spouses EI Premiums (Line 312 of Income Tax Return): Spouses CPP Contributions (Line 308 & 310 of Income Tax Return):

Mothers Income Tax Payable (Line 435 of Income Tax Return):

Fathers Income Tax Payable (Line 435 of Income Tax Return):

Spouses Income Tax Payable (Line 435 of Income Tax Return):

Self-Employment: If a parent or spouse was self-employed in any of the years requested above, we will require a copy of the business statements that relates to that particular taxation year. Please submit with your application. Documentation of Parental / Spousal Income: Copies of your parent / spouses personal income tax return notice of assessment may be requested. Please be prepared to submit copies of the tax assessment. We will contact you if we require this documentation.

Family Asset Information (Required for all applicants)

(Include totals for both parents) Mutual Funds (estimated FMV @
Feb/12):

GICs: Parents: Student: Stocks (estimated FMV @ Feb/2012):

Parents: Student:

Total Bank Account Balances ( at

Feb 2012): Parents: Student:

Parents: Student: Term Deposits: Parents: Student: Total Value of Investments Held Outside Canada: Parents: Student:

Other: Parents: Student:

Bonds (face value): Parents: Student: RRSPs (at Feb 2012) Parents: Student:

Real Estate (Attach and additional sheet if required) Parental Primary Residence Address: Personal Primary Residence (if different from Parental) Address: Recreational Property / Other Type: Address:

Market Value (from latest Property Tax Assessment): Mortgage Owing:

Market Value (from latest Property Tax Assessment): Mortgage Owing:

Market Value (from latest Property Tax Assessment): Mortgage Owing:

Not applicable. Renting.

Not applicable. Renting.

Non-Registered Investments - Documents supporting the value of all non-registered investments may be required. Please be prepared to submit investment statements as applicable. We will contact you if we require this documentation. If you hold financial interests (shares) in private businesses/corporations please include all audited financial statements. Real Estate Copies of the latest property assessment are required. Please submit a copy of the most recent property assessment with your application.

STATEMENT COMPONENT (Please attach to this form) Please describe in 250 - 500 words on how your activities contribute to your home, community or school and impact the lives of others.

SUMMER ACTIVITY COMPONENT Please describe how you spent the majority of your last 2 summers and whether you were able to accumulate any summer savings to help fund your education. Summer 2011

Summer 2010

Please describe how you will be spending the majority of your summer and whether you were able to accumulate any summer savings to help fund your education. Summer 2012

I understand that if any information is found to be untrue or inaccurate, this application may be considered cancelled and any money received as a result will have to be returned. If additional financial resources (eg. sponsorships, external awards/scholarships, service medical agreements) become available after this application is signed, you must disclose the information to our office during the application process and if you are a successful recipient of this scholarship

Date

Signature

The information on this form is collected under the authority of the University of Western Ontario Act, 1982, as amended, and is needed to process your application, and decide your eligibility for the Schulich Scholarship. Registrarial Services may disclose to the award donor, who may use your information in publications associated with the bursary/award, and share with the appropriate Faculty, Department(s), and School(s) the following student personal information: name, address, biographical data, faculty, academic programs, and any other information that confirms criteria to the donor of the bursary or award. If you have any questions or concerns about the collection, uses, and disclosure of this information by the University, please contact the Training and Security Team Leader, Registrarial Services, Stevenson-Lawson Building Room 155B, The University of Western Ontario, London, ON, N6A 5B8, tel: 519-661-2111, extension 82680.