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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


Memorial Scholarships for Families of Deceased Firefighters, Volunteer Firefighters, Police Officers, Peace Officers and Emergency Medical Service Workers Supplement Form
HESC  We Help People Pay for College
 
 
This supplement is used to initially establish eligibility for the 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 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      
FIREFIGHTER, VOLUNTEER FIREFIGHTER, POLICE OFFICER, PEACE OFFICER, EMERGENCY MEDICAL SERVICE WORKER INFORMATION
8.   Social Security Number 9.   Date of Birth (Use numbers only)
   
        Month      Day           Year        
10.   Last Name First Name MI
       
11. Agency or Department    _______________________________________________________________
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 ________________



Personal Privacy Protection Law Disclosure of social security Numbers
Information provided on this supplement will be maintained in an applicant file by the Division of Grants and Scholarships of the New York State Higher Education Services Corporation.The Director of Grants and Scholarship Processing, HESC, 99 Washington Ave., Albany, New York 12255, 1-888-697-4372 is responsible for the maintenance of these records. This information is required to determine eligibility for a Memorial Scholarship for Families of Deceased Police Officers, Peace Officers,Firefighters and Emergency Medical Service Workers for which this supplement is submitted and will be released to your school for purposes of verification. Failure to provide information requested may result in the denial of an award. This iniformation is being collected under the authority of New York State Education Law §661, subdivision (2).   Disclosure of your social security number is mandatory and has been authorized by NYS Education Law §661, subdivision (2).
We need these numbers to process your supplement, to keep your records, and to confirm the information which you provide.

NO DISCRIMINATION ON THE BASIS OF DISABILITY
We do not discriminate against disabled persons in our employment practices or in the administration of our programs, activities or services.
HE8099  (Rev. 03/2003)