Form BIA 6237 BIA 6237 Higher Education Grant Application

BIA Form 6237 OMB Control No. 1076-0101

Expires: 11/30/2007

HIGHER EDUCATION GRANT APPLICATION

Name:_______________________________________________________ Social Security No.________________

Last First MI Maiden

Address:_____________________________________________________________________________________

Street City State Zip

Telephone:________________________ Email Address:_______________________________________________

Date of Birth:______________ Sex: Male Female Tribal Affiliation:________________________________

Name & Address of High School:_________________________________________________________________

H.S. Graduation/GED Date:_________________

APPLICATION REQUEST: 20_____ 20_____

Academic Year Spring Only Fall Only Summer Full-Time Part-Time

Name & Address of Institution Selected:____________________________________________________________

College Major:_____________________________ Expected Graduation Date:_____________________________

Expected Degree: AA BA BS Other___________________

Year in College: Freshman Sophomore Junior Senior

Have you ever received a BIA grant before? Yes No What years?_____________ Sem/Qt Hrs__________

Privacy Act Statement: This information collection document contains information that is covered under the Privacy Act, as amended. The Bureau of Indian Affairs will not disclose any record containing such information without the written consent of the respondent unless the requestor uses the information to perform assigned duties. The primary use of this information is to verify and rate Indian students who apply for grant aid. Examples of others who may request the information are U.S. Department of Justice or in a proceeding before a court or adjudicative body; Federal, state, local, or foreign law enforcement agency; Members of Congress; Department of Treasury to effect payment; a Federal agency for collecting a debt; and other Federal agencies to detect and eliminate fraud. Collection of your Social Security Number is authorized by 31 U.S.C. 7701.

DECLARATION OF PURPOSE: I declare I will use any funds received through the Bureau of Indian Affairs Higher Education Grant Program solely for expenses connected with enrollment at an accredited institution of higher learning. I request that any BIA grant awarded me to be mailed to me in care of the financial aid office of the institution.. I will provide a copy of my academic transcript to the BIA funding office at end of each academic term.

Paperwork Reduction Act Statement: This information is collected to manage higher education grants. The information is supplied by a respondent to obtain or retain a benefit, that is, a grant . It is estimated that responding to the request will take an average of 60 minutes to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the form, please send them to the Information Collection Control Officer, Bureau of Indian Affairs, 625 Herndon Parkway, Herndon, VA 20170. Note: comments, names and addresses of commenters are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and expiration date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB clearance number.

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Signature of Student Date

FINANCIAL AID PACKAGE SECTION

PART 1: TO BE COMPLETED BY THE STUDENT

Name:_________________________________________________________ SSN:_________________________

Address:_____________________________________________________________________________________

City State/ZIP

Telephone:__________________________ Email:_____________________________________

I grant permission for the institution to release financial and academic information to the Bureau of Indian Affairs. The Bureau’s office will require the financial aid information listed in Part 2 before any determination will be made with my application for assistance. When the necessary information has been completed please forward this form to the following address:

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Student Signature Date

PART 2: TO BE COMPLETED BY THE INSTITUTION’S FINANCIAL AID OFFICER

This student has applied to the Bureau of Indian Affairs Higher Education Office for a grant. Verified financial aid information is required from your office before any determination can be considered with this application. Please complete and forward this form to the following address:

Student Standing: Independent Dependent School Operated Upon: Semester Quarter

BUDGET PERIOD - FROM________________TO __________________ Start Date:______________________

COLLEGE BUDGET STUDENT RESOURCES & INSTITUTIONAL AWARD

Tuition __________ Parental Contribution___________ SEOG ____________

Fees __________ Student/Spouse Contr___________ Pell ____________

Room/Board __________ AFDC/Welfare ___________ Perkins ____________

Books __________ VA Benefits ___________ Stafford ____________

Travel __________ Social Security __________ CWS ____________

Miscellaneous __________ State Grants ___________ Voc Rehab ____________

State Indian School ___________ Scholarship _____________

Other _____________

Total Costs $_________ Total Resources $____________

Recommended award from the BIA $____________________

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Financial Aid Officer Signature Date Telephone

Name & Address of Institution:__________________________________________________________________

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