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New York State Higher Education Services Corporation
99 Washington Avenue · Albany, New York 12255
1-888-NYS-HESC (1-888-697-4372)
www.hesc.org

New York State World Trade Center Memorial Scholarship Application
HESC We Help People Pay for College
 
This application is used to initially establish eligibility for the World Trade Center Memorial Scholarship. It is NOT an application for payment. A separate application for payment MUST be submitted by May 1 of the academic year for which payment is requested. Be sure to read the instructions regarding How to Apply for a World Trade Center Memorial Scholarship.       Please print or type.
APPLICANT INFORMATION
1.  
Social Security Number
 2. Date of Birth (Use numbers only)   3.  Telephone Number
            
        Month      Day           Year     
 
4.   Last Name First Name MI
     
5.   Address: number, street, apartment
 
  City or Town State Zip Code
 
6. Email Address   ______________________________________________________________
   
7. In what month and year will you or did you begin college?  
      Month          Year      
  Name of college ____________________________________________  
 
8.   Relationship to deceased/disabled
(See instructions for required documentation)		  Self Spouse Child
Financial Dependent
 
INFORMATION ON DECEASED OR DISABLED FAMILY MEMBER
(See instructions for required documentation)  
9.   Social Security Number 10.   Date of Birth (Use numbers only)
        
        Month      Day           Year        
11.   Last Name First Name MI
 
   
APPLICANT/LEGAL GUARDIAN AFFIRMATION
12.   I affirm the information herein is true. This information will be accepted for all purposes as the equivalent of an affidavit and if it contains a false statement, shall subject me to the same penalties for perjury as if I had been duly sworn.

I consent to the verification by NYS Higher Education Services Corporation (HESC) of any statement made herein. I further consent to the release by HESC of such information as may be provided by law or regulation in the course of financial aid program administration.
Signed __________________________________________________    Date ________________
HE8227  (Rev. 03/2003)