Form USCGA-AIM1 AIM Scholarship Request Form

AIM Scholarship
Request Form
AIM - 1

Privacy Notice. In accordance with 5 USC 552a(e)(3), the
following information is provided to you when supplying personal
information to the USCG. (1) Authority which authorizes the
solicitation of the information: 14 USC 182. (2) The Principal
Purpose for this information is to determine financial need for
scholarship opportunities. (3) Disclosure of the information is
voluntary, but the applicant will not be considered further for
scholarship benefits if the information is not provided.

AIM Coordinator (tw-c)
U.S. Coast Guard Academy
31 Mohegan Avenue
New London, CT 06320

860-444-8503 (phone)
860-701-6700 (fax)
www.uscga.edu
[email protected]

The U.S. Coast Guard Academy Admissions Office has a limited amount of funds to provide scholarships for students
with legitimate financial need. If you wish to apply for a scholarship, you must submit the information below. The
questions below are derived from the FAFSA (Free Application for Federal Student Aid) Pre-Application Worksheet and
will be used only for the purpose of determining financial aid eligibility for the U.S. Coast Guard Academy Admissions
Programs. When filling out the document, “you” refers to the student.
Student’s legal name (must match driver’s license or
federal identification):

Last Name
First Name
M.I.

Student’s date of birth:
Student’s gender:

Male

Female

Which scholarship(s) are you applying for?

Travel

Fee

Name of the Admissions program you are applying for: Academy Introduction Mission 2019
Your Father’s educational Level:

High School

College or Beyond

Your Mother’s educational Level:

High School

College or Beyond

If an orphan, are (or were) you a ward/dependent of the state?
Have you (student) completed an IRS or other income tax return
in the past year?
If so, what income tax return did you file?

Yes

No

Yes

No

IRS 1040
IRS 1040A
1040 EZ or 1040 Telefile
If you (student) filed a 1040, were you eligible to file a 1040A
Yes
or 1040EZ?
What was your (student) adjusted gross income last year?
What was the amount of your (student) income tax last year?
How much did you (student) earn from working (wages, salaries, tips, etc.) last
year?
How many people currently live in your household?

Foreign Tax Return
No
$
$
$

#
#

How many of your brothers and sisters are attending college?
As of today, what is the net worth of your (student) current investments,
$
including real estate?
As of today, student’s net worth of current business and/or investment farms:
$
As of today, student’s amount of cash, savings, and
$
checking accounts:
What is your parents’
Married
Unmarried
Divorced/Separated
current marital status?
Month and year your parents were married, separated, divorced or widowed (if
applicable)
Have your parents completed an IRS or other income tax form in
Yes
the past year?
If so, what type of income tax return did your parents file last year?
IRS 1040
IRS 1040A
1040 EZ or 1040 Telefile
If your parents filed a 1040, were they eligible to file a 1040A
Yes
or 1040EZ?
What was your parents’ adjusted gross income last year?
$
What was the amount your parents’ income tax last year?

$

Widowed

No

Foreign Tax Return
No

How much did your parents earn from working (wages, salaries, tips, etc.) last
year?
As of today, parents’ net worth of current investments, including real
$
estate (not home):
As of today, parents’ net worth of current business and/or investment
$
farms:
As of today, parents’ amount of cash, savings, and checking accounts:
$

$

In order to process travel forms, we will need the following information:
Student’s mailing address (if you have a PO Box please
include physical address as well):
Are you (student) a federal employee?
Is parent/legal guardian a federal employee?
Parent/legal guardian’s legal name (must match driver’s
license or federal identification):

Last Name
First Name
M.I.

Parent/legal guardian’s date of birth:
Parent/legal guardian’s gender:

Male

Female

Relationship to student of parent/legal guardian attending:
Student’s traveling contact phone number:
Traveling contact phone number of parent/legal
guardian:
Closest airport to your home:
Second closest airport:
Please keep in mind, depending on your proximity to the Academy, the train may be an option.

Student Signature: ____________________________________________________

Date: ________________________

Student Email: _____________________________________________________________________________________________
Parent/Legal Guardian Signature: ______________________________________

Date: __________________________

Parent/Legal Guardian Email: _______________________________________________________________________________

NOTE: Requesting a scholarship does not necessarily grant the scholarship. CGA Admissions will
assess financial need; those who qualify for the scholarship will be contacted by the CGA Admissions
Office with further instructions.
Please return this form to the Admissions Office, "ATTN AIM Scholarship" by May 19th 2019:
AIM Coordinator (tw-c)
U.S. Coast Guard Academy
31 Mohegan Ave.
New London, CT 06320

Email: [email protected]
Fax: 860-701-6700

OMB Control No.: 1625-0121
Expiration Date: 05/31/2018
PRA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a valid OMB control number. The United States Coast Guard estimates that the average burden per response for this
report varies per applicant - about three hours for completion of the online application, including personal statements, and up to two hours
to complete all supplemental forms. You may submit any comments concerning the accuracy of this burden estimate or any suggestions
for reducing the burden to: U.S. Coast Guard Academy, Admissions Office, 31 Mohegan Avenue, New London, CT 06320 or Department of
Homeland Security Desk Officer, Office of Management and Budget, Office of Information and Regulatory Affairs, Washington, DC 20503.