JEWISH FEDERATION OF METROPOLITAN CHICAGO 2016 SPRING HIGH SCHOOL

ISRAEL EXPERIENCE SCHOLARSHIP APPLICATION

1. Detailed copies of all pages and Schedules of your most recent (can be either 2015 OR 2014) Federal Income Tax Return Form 1040, 1040A or 1040EZ (as filed with the IRS) for parents and guardians listed, plus applicant (if appli-cable). Recaps and/or Summary Forms are not acceptable. If you file Schedule A, B, C, D, E or F, you must provide copies. If you do not have a tax return for either of these last two years (2015 or 2014), please contact 312-444-2895.

2. Copies of all 2015 AND 2014 W-2 Wage and Tax Statement Forms, all 2015 AND 2014 1099/1099R for Pensions/Annuities and/or Misc. Income Forms for parents and guardians listed, plus applicant (if applicable). Please make

sure all documentation is copied on regular 8 1⁄2 x 11 paper.

3. This application form filled out in its entirety, signed and dated by the parent(s), guardian(s) and applicant listed.

4. Verification of program costs from sponsoring organization (webpage printout, brochure or letter from organization).

5. Written statement by applicant briefly describing why s/he chose THIS PROGRAM in Israel (up to one page).

IMPORTANT: If the above items do not accompany this application,

your application will not be considered complete.

For programs beginning Summer 2016 through Fall 2016

This application must be submitted/postmarked no later than March 1, 2016 ELIGIBILITY & GUIDELINES:

1. Eligibility: Demonstrate financial need. Reside in metropolitan Chicago. Applicants living outside Illinois but attending school in the Chicago area are

not eligible to apply. Applicants presently in school outside of the U.S. are also not eligible to apply. Be enrolled in grades 9, 10, 11 or 12 as of September 2015. Have already applied to an approved Israel Experience program of work, study or travel in Israel which does

not begin until after the application deadline. However, you may apply for a scholarship before you have received your acceptance to the program.

Be available to participate in an in-person interview along with at least one English-speaking parent or adult guardian (to be contacted when your completed application has been received).

Participate in Jewish communal activities when you return from Israel.

2. Siblings: Families may apply for only one Jewish Federation Israel Experience financial need scholarship in any one academic year, except in the instance of twins/triplets/other multiples. For example, a sophomore and a senior could not apply in the same year, nor could a college student and a high school student from the same family. Applicants must wait a full year before applying for a second Federation financial need scholarship and are only eligible to do so if the second program is substantially different from the previous program.

3. Returning participants: Although students who have traveled to Israel before, with or without the help of a Jewish Federation scholarship, are eligible to apply, priority will be given to first-time participants. Jewish Federation scholarships cannot be used to extend a current program or for programs that are substantially similar to a program in which the applicant has already participated.

4. Students currently in Israel: Whether or not you have received a Jewish Federation scholarship for your current program, if you are in Israel during the application period you are not eligible to apply for a scholarship. Furthermore, only one Jewish Federation scholarship may be applied to any given Israel Experience program, and scholarships cannot be used for programs that are substantially similar to a program in which you have already participated.

5. Income guidelines: Please keep in mind that our funds are limited and requests always greatly exceed demand. We work hard to make sure that the neediest families are given priority. While we do take into account the family’s total financial picture, families earning in excess of $130,000 annually should contact our offices at 312-444-2895 before submitting an application.

TO COMPLETE YOUR APPLICATION, YOU WILL NEED TO INCLUDE:

IMPORTANT INFORMATION → The goals of the Jewish Federation Israel Experience scholarship program are to develop increased

Jewish identity, greater commitment to Israel and the Chicago Jewish community, and leadership in the Jewish community.

→ Although we ask about the applicant’s activities, please understand that this is not a merit scholarship application

and that prior involvement in Jewish communal activities is not a requirement for receiving a financial need-based scholarship.

→ Jewish Federation scholarship funds are limited, and we have many requests for financial assistance. Therefore,

we must examine the resources of each family carefully to be sure that the scholarships are granted to the applicants deemed most in need of financial assistance. Please understand that the basic requirement for a Jewish Federation scholarship is the demonstration of financial need. While income alone is not the only determinant of financial need, applicants from families with lower incomes will usually receive higher priority than applicants from families with higher incomes. Please note: Applicants with Federation Israel Experience Savings (including SKIP, Gift of Israel, Bar/Bat Mitzvah Certificates and Walk with Israel Vouchers) are expected to use these funds toward the cost of the Israel Experience program when applying for a financial need scholarship.

→ No full scholarships are awarded. Applicants are required to seek other financial assistance in addition to the

Jewish Federation Israel Experience scholarship. Possible sources of other assistance include the sponsoring organization of the Israel Experience program and the synagogue or religious day school, if applicable. For information regarding other scholarship resources, visit http://www.juf.org/israel_experience/other_scholarship.aspx. However, public solicitation of funding will make a family ineligible for Federation funding. We expect parents to make an appropriate contribution toward the cost of the program, and we expect that applicants will also contribute toward the cost of their trip.

→ Applicants must apply to an approved Israel Experience program (which does not begin until after the application

deadline) before they are eligible for apply for a Federation scholarship. They can, however, apply for a scholarship before being accepted to the Israel Experience program. However, they MUST be accepted to the Israel program before they can receive any scholarship funds.

→ Federation will treat each application and all of the information provided with the strictest confidentiality. Names

and other identifying information will not be included in any materials sent to the Scholarship Committee. → The Scholarship Committee of the Federation will make the final decisions on the awarding of scholarships after

assessing each applicant's situation on an individual basis and in comparison to the other applicants. Remember that this is only an application for financial assistance and that no guarantee or promise of receiving a scholarship can be made until the Scholarship Committee reaches its decisions.

→ Applicants will be notified of the Scholarship Committee's decision on the scholarship request, by email and mail,

by late May. No information on scholarship awards will be given by phone. The balance of fees due to the program is each applicant’s responsibility. If the applicant fails to complete the Israel Experience program, s/he will have to repay the scholarship award to the Jewish Federation of Metropolitan Chicago.

→ We ask that you provide any other information that you think would be helpful to us in making our evaluation of

your application.

QUESTIONS? israelexperience@juf.org

312-444-2895

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JEWISH FEDERATION OF METROPOLITAN CHICAGO 2016 SPRING HIGH SCHOOL

ISRAEL EXPERIENCE SCHOLARSHIP APPLICATION

Funded by the Naftali Steinfeld Memorial Scholarship Fund for Israel Experiences and the Jewish Federation

Final Deadline for Submission: March 1, 2016

PLEASE TYPE OR PRINT NEATLY IN INK

FUNDING CHART: Please use the chart below to indicate your program costs and expected funding. In order

for your application to receive serious consideration, you MUST seek additional sources of financial assistance

Name _______________________________ __________________________________ _________________________________

(Last) (First) (Middle)

Gender M F Age ________ Date of birth ____/_____/______ Birthplace ____________________________

Social Security number _______________________________________ Email _______________________________________

Home address ______________________________________________________ Phone (_______) ______________________

City ________________________________________________ State_________ ZIP ________________________________

High school ________________________________________________________ Present year Fr. So. Jr. Sr.

Israel Experience program ____________________________________________________________________________________

Sponsoring organization ______________________________________________________________________________________

Program term Summer Semester Year Other (Please specify) ________________________________

Date program begins _________________________ Date of return _________________________

COSTS FUNDING

Program/Tuition $___________________ Applicant contribution $___________________

Travel to Israel /New York

(if not included above) $___________________

Parent contribution $___________________

$___________________

SKIP/Gift of Israel/Bar-Bat

Mitzvah Certificate Spending money $___________________

Meals (not included in tuition) $___________________ Congregation contribution $___________________

HTC/TI/YU fee (if applicable) $___________________ Israel Program Contribution $___________________

Other costs (please specify) $___________________ Other sources (please specify) $___________________

__________________________ $___________________ ________________________ $___________________

__________________________ $___________________ ________________________ $___________________

FEDERATION REQUEST $___________________

TOTAL $___________________ TOTAL $___________________

PROGRAM INFORMATION

APPLICANT GENERAL INFORMATION

Please note: List all organizations, IN ADDITION to FEDERATION, to which you applied or intend to apply for financial assis-

tance, and the amount requested. Make sure costs and funding totals balance and a FEDERATION REQUEST is stated.

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Relation to applicant: _____________________________________

________________ _________________________ _______ Last Name First Name MI

__________________ _____ (______) _________________ Title (Dr, Rabbi, Etc.) Age Home Phone

_________________________________ ________________

Home Address Apt. #

__________________________ ________ ______________ City State ZIP

(_____) _______________ __________________________ Work Phone Email address

______________________ __________________________ Employer Occupation

Full-time Part-time If part time, number of hours per week __________

(_____) _______________ __________________________ Cell phone Best place to reach you by phone?

1. Did your family come to the U.S. from another country? Yes No

If yes, please list the country ________________________________ and date of arrival in U.S. (month/year) _______.

2. Parents' Marital Status: Married Single, Never Married Widowed Remarried Both deceased

Separated Divorced—If divorced or separated, complete questions a through e.

a. Date of divorce or separation (month and year) ________________________

b. Custodial parent: Mother Father Joint custody Custodial parent has remarried—>Date ___________

c. Who will claim applicant as a tax dependent for 2015? Mother Father

d. How much will each parent pay for

2015-16 day school tuition Mother $_____________ Father $_____________

2015-16 college costs Mother $_____________ Father $_____________

Israel Experience program cost (p. 1) Mother $_____________ Father $_____________

e. Permission to contact: Parent/Guardian 1 Parent/Guardian 2 Both

General Family Information

Parent/Guardian 1 Information Parent/Guardian 2 Information

3. Children in family

a. Total # of children in family (including married/independent children) _______

b. Total # of individuals residing in household during 2015 (including parents, children and others) _______

(mark “married” or “independent” in the School column where appropriate, and list any parental support in the Tuition/Housing column)

(List all children; attach additional pages if needed) Child’s Name Age School

Grade/

year

Public/

Private

Scholarships

for 2015-16

Tuition/Housing PAID BY FAMILY

for 2015-16

Additional Support for

2015-16

1

2

3

4

5

Relation to applicant: ______________________________________

__________________ _______________________ _______ Last Name First Name MI

__________________ _____ (______) _________________ Title (Dr, Rabbi, Etc.) Age Home Phone

__________________________________ _______________

Home Address Apt. #

___________________________ _______ ______________ City State ZIP

(_____) _______________ __________________________ Work Phone Email address

______________________ __________________________ Employer Occupation

Full-time Part-time If part time, number of hours per week __________

(_____) _______________ __________________________ Cell phone Best place to reach you by phone?

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i. Please list source(s)/type(s) and value(s) of income reported in rows c and g above.

j. Please list the source and amount of community assistance your family receives, if any, listed in row h above.

2. Assets/Debts

a. Please list TYPE and VALUE of your assets.

1. Income (taxable and non-taxable)

2014 2015

Estimated

2016

a. Gross salaries and wages from W-2 forms

(including non-taxable retirement

contributions and flex benefits)

do NOT include parsonage

Parent/Guardian 1

Parent/Guardian 2

Parent/Guardian 1 b. Dividend and/or interest income from 1099 forms

(including non-taxable interest) Parent/Guardian 2

c. Other income: business, rent, royalties, trusts,

unemployment comp, Social Security benefits,

scholarship, etc. from 1099, K-1, etc.

please see line i below

Parent/Guardian 1

Parent/Guardian 2

d. Parsonage (do not include in salary above)

e. Alimony/maintenance received annually

f. Child support received for all children annually

g. Government assistance (public aid, food stamps,

SSI disability/death benefits, etc.)

please see line i below

h. Community assistance (i.e. from family, friends,

Chesed Fund, etc.) please see line j below

AMOUNT AMOUNT

Checking/savings accounts $________________________ Retirement (pension

funds, 401(k), IRA, tax

deferred annuity, etc.) Money Market / CDs $________________________ $________________________

Stocks/bonds/mutual funds $________________________

Other (specify type and

amount) _____________ $________________________

Real estate (not including

family residence)/business $________________________ ____________________ $________________________

PARENTS’ FINANCIAL INFORMATION (Please provide all information requested)

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b. Residence. Do you own your primary residence? Yes No

i. If yes, is it a home townhouse condo?

Purchase year __________ Cost $_________________ Current mortgage balance $________________

Estimate present market value $_____________________

Monthly mortgage payment (do not include ARET) $_______________ Annual real estate taxes $_________________

ii. If no, do you rent an apartment house? Monthly rent $________________

c. Autos. Please list make, model and year of your vehicles. Add an additional page, if necessary.

Make/Model ______________________ Year ________ Owned Leased ________cost/month Provided by employer

Make/Model ______________________ Year ________ Owned Leased ________cost/month Provided by employer

Make/Model ______________________ Year ________ Owned Leased ________cost/month Provided by employer

d. Debts. Please list the type and amount of debts, including mortgage balance, personal and business loans, educational loans,

credit card balances, auto loans, etc., as well as the purpose of each. Add additional pages if necessary.

e. Medical expenses. The cost of our annual insurance premiums is $_________. This is paid by [please check all that apply]:

out-of-pocket ($_____), pre-tax dollars ($_____), my employer ($_____). If you had significant UNREIMBURSED medical expenses other than these insurance premiums last year or this year, or expect

to have such expenses next year, please list amounts and explain.

AMOUNT OF UNREIMBURSED EXPENSE YEAR EXPLANATION

$_____________________________ ______________ _______________________________________________________

$_____________________________ ______________ _______________________________________________________

$_____________________________ ______________ _______________________________________________________

Source of Debt Amount remaining Purpose: Business/Personal

Mortgage

Credit card debt (personal) Personal

Credit card debt (business) Business

Other business debt Business

Auto loan

Educational loan

Other (specify)

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1. Current employment

Present position ___________________________________________________ Monthly earnings $______________________

Work place _______________________________________________________________ Hours/week ____________________

Address _________________________________________________________ Phone (____)____________________________

How long have you been working at this job? __________________________________

2. Summer employment (2015)

Position(s) ________________________________________________________ Total earnings for summer $______________

Work place _____________________________________________ Hours/week__________ No. of weeks_______________

Address ______________________________________________________ Phone (______)____________________________

*If you did not work, what did you do? _______________________________________________________________________

3. Do you drive a car primarily for your use? No Yes—> Make, model, and year: _____________________

4. Assets. List all assets in your name or held for you.

5. Annual gross income in 2014 $_____________ 2015 $_____________ Anticipated 2016 $_____________

6. Jewish involvement

a. Previous trips to Israel (add extra page if necessary)

b. Previous scholarships awarded to applicant by Jewish organizations or agencies:

c. Synagogue Name _____________________________________________________________________________________

Check one Reform Conservative Reconstructionist Traditional Orthodox Other: __________________

d. Involvement with Jewish communal activities (including dates and offices held):

e. Extracurricular activities (including dates and offices held):

f. Awards and honors:

7. Attach a brief statement (up to 1 page) explaining why you chose THIS PROGRAM in Israel.

YEAR LENGTH OF STAY PURPOSE SPONSORING ORGANIZATION

_____________ ___________________ _________________________ ____________________________________

_____________ ___________________ _________________________ ____________________________________

ORGANIZATION/AGENCY PURPOSE AMOUNT DATE

_______________________________ _______________________ ____________________ ___________________

_______________________________ _______________________ ____________________ ___________________

APPLICANT'S FINANCIAL INFORMATION AND BACKGROUND

For your application to be accepted, items 1-7 MUST be completed by applicant, not parent.

Savings account $ ________________

College Savings Accounts $ ________________

Stocks/bonds/mutual Funds $ ________________

Checking account $ ________________

Money Market accounts/CDs $ ________________

Other : ___________________ $ ________________

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SPECIAL CIRCUMSTANCES: Is there anything else you think would be helpful for us to know? Please explain any

special circumstances which might be of help in determining scholarship need. Indicate any unusual expenses or significant

changes in income in the last two years or anticipated next year for your family, as well as family illness, job changes, moves, etc.

Yes No

Yes No

Yes No

Yes No

____________________________________________ ________________________________ (Applicant's signature) (Date) ____________________________________________ ________________________________ (Signature of parent/guardian 1) (Date) ____________________________________________ ________________________________ (Signature of parent/guardian 2) (Date)

Mail completed application materials to: Jewish Federation of Metropolitan Chicago Israel Experience Department 30 S. Wells St., Room 5031 Chicago, IL 60606

ALL APPLICATION MATERIALS MUST BE SUBMITTED (OR POSTMARKED) BY

MARCH 1, 2016

ATTESTATION FORM

This application is complete and includes a signed copy of the family’s (and applicant’s, if applicable) most

recent federal tax return(s) (this can be for either 2015 OR 2014, and must include ALL schedules and

statements), W-2 and 1099 forms for 2014 AND 2015, the applicant’s written statement, and the verification of

programs costs (letter/brochure/webpage printout).

**Note: your application will NOT be considered without ALL of these items**

I have already applied to the Israel Experience program listed on this application.

I attest to this application being true & correct to the best of my knowledge, and I authorize you to check its

validity. I understand that this is only an application for a scholarship and that there is no guarantee of receiving

a scholarship. I understand receipt of a scholarship is contingent upon acceptance to the program to which I

have applied and that failure to complete the program will necessitate repayment of the scholarship.

I confirm that I have read the Scholarship Guidelines and Information thoroughly and completely and have

kept a copy for my files.

*Please note—PC users only*

If you are submitting this form via email, simply type in the required names and dates above.

There is no need to print and sign it—submitting your form via email constitutes your electronic signature.

OR

PC users ONLY (Mac OS not supported) You may email completed application materials to: israelexperience@juf.org *Please save this application as a PDF file and attach it to an email. No other file format will be accepted.