INCOME-BASED TUITION APPLICATION

Student Name:*
StudentEmail:*
Student SSN:(if applicable)
Parent Name:*
Parent Email:*
Parent SSN:(if applicable)
Address:*
City:*
State, Territory, or Country:*
Zip or Postal Code:*
Is the Student a citizen of the United States?*
Home Phone:*

--------------------------------------------------------------------------------------------

In order to process your request, please answer the questions below. ROA will be unable to process your request without the information. All applicants are given the same attention without regards to race, creed, national origin, religion, sex, disability, or source of income

--------------------------------------------------------------------------------------------

Please list the names, ages, and gross income (even if zero) of all members of your household.

For those who provide income to your household, please show the income amount and explain where it comes from.

Sources of income may include wages, child support, Social Security benefits, Veteran's benefits, retirement or pension income, educational grants or scholarships, gifts, loans, interest on financial accounts, etc.

Name Age Monthly Income Source Of Income
1.
2.
3.
4.
5.

--------------------------------------------------------------------------------------------

Please state the amount for utility expenses for the following:

Electricity:*
Gas:*
Water/Sewer:*
Phone:*

Please state the amount for:

Mortgage/Rent:*
Car Payment:*
Car Insurance:*
Home Owner Insurance:*
Credit Cards:*

--------------------------------------------------------------------------------------------

Do you have heating and/or cooling expenses that are separate from your rent or mortgage payment?

Have you applied for or received HEAT assistance in the last twelve (12) months?

--------------------------------------------------------------------------------------------

Digital Signature MUST be done by parent or guardian of the student and that parent or guardian MUST be over the age of 18.

I am over 18:

I have read all statements above:

I understand all statements read:

Please type in your initials and todays date to act as signature verifying all information is correct:
Initials:* Date:*

--------------------------------------------------------------------------------------------

By clicking the Send button here, you are digitally signing this request and you are confirming that you, the digital signer are over the age of 18.

If you have more than one student, please submit one application for each student. Your application will be processed as quickly as possible. Once the application has been processed, we will send you an agreement for you to physically sign. This agreement will explain the decision made.