Memorial Scholarship for Families of Deceased Firefighters, Police, Peace Officers and Emer.Med.Workers Supplement

	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

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)