CICF Designated Scholarship Recipient Form

Central Indiana Community Foundation (CICF) requires the designated entity to complete this form for each scholarship recipient prior to the release of funds. We intend to use this information to track persistence and completion among all scholarship recipients. This form should only take about 20 minutes to complete.

IMPORTANT: You are NOT able to save a partial copy of this form, meaning you must complete it without reloading or navigating away from the page.

Scholarship Fund Information

How many recipients will be getting a scholarship for this fund this year?
S

Organization EFT Information

Distributions will be made via an electronic funds transfer for the organization listed above's checking account.
Are you the person who can confirm the EFT Payment Information?

Recipient #1's Information

As it appears on birth certificate or official documentation
S
Please input date (MM/DD/YYYY)
Recipient's Permanent Address
Recipient's Permanent Address
Line 1
Line 2
City
State/Province
Zip/Postal
County of Residence

Recipient #1's High School Information

Please enter recipient #1's high school information.

Recipient #1's Current G.P.A

Please enter recipient #1's current G.P.A. regardless of whether they are in high school or college.

Recipient #1's Post-Secondary Information

Please enter recipient #1's collegiate information.
College Address
College Address
Line 1
Line 2
City
State/Province
Zip/Postal

Recipient #1's Demographic Information

The demographic information you provide to CICF is very important. It will allow us to ensure that our scholarship program is achieving our mission of helping students earn a post-secondary credential.

CICF respects an individual's right to keep certain personal information private. Any information provided in this demographic questionnaire will be used by CICF for the important purpose of improving our scholarship program. If you have any questions or concerns regarding the information you provide in this form, please contact scholarships@cicf.org.

Recipient's Gender
Recipient's Race
Recipient's Ethnicity
Was the recipient eligible for free or reduced-price meals in high school?
Was the recipient the first in their family to attend a post-secondary institution to attain a post-secondary credential?
Is the recipient a 21st Century Scholar?

Recipient #2's Information

As it appears on birth certificate or official documentation
S
Please input date (MM/DD/YYYY)
Recipient's Permanent Address
Recipient's Permanent Address
Line 1
Line 2
City
State/Province
Zip/Postal
County of Residence

Recipient #2's High School Information

Please enter recipient #2's high school information.

Recipient #2's Current G.P.A

Please enter recipient #2's current G.P.A. regardless of whether they are in high school or college.

Recipient #2's Post-Secondary Information

Please enter recipient #2's collegiate information.
College Address
College Address
Line 1
Line 2
City
State/Province
Zip/Postal

Recipient #2's Demographic Information

Recipient's Gender
Recipient's Race
Recipient's Ethnicity
Was the recipient eligible for free or reduced-price meals in high school?
Was the recipient the first in their family to attend a post-secondary institution to attain a post-secondary credential?
Is the recipient a 21st Century Scholar?

Recipient #3's Information

As it appears on birth certificate or official documentation
S
Please input date (MM/DD/YYYY)
Recipient's Permanent Address
Recipient's Permanent Address
Line 1
Line 2
City
State/Province
Zip/Postal
County of Residence

Recipient #3's High School Information

Please enter recipient #3's high school information.

Recipient #3's Current G.P.A

Please enter recipient #3's current G.P.A. regardless of whether they are in high school or college.

Recipient #3's Post-Secondary Information

Please enter recipient #3's collegiate information.
College Address
College Address
Line 1
Line 2
City
State/Province
Zip/Postal

Recipient #3's Demographic Information

Recipient's Gender
Recipient's Race
Recipient's Ethnicity
Was the recipient eligible for free or reduced-price meals in high school?
Was the recipient the first in their family to attend a post-secondary institution to attain a post-secondary credential?
Is the recipient a 21st Century Scholar?

Recipient #4's Information

As it appears on birth certificate or official documentation
S
Please input date (MM/DD/YYYY)
Recipient's Permanent Address
Recipient's Permanent Address
Line 1
Line 2
City
State/Province
Zip/Postal
County of Residence

Recipient #4's High School Information

Please enter recipient #4's high school information.

Recipient #4's Current G.P.A

Please enter recipient #4's current G.P.A. regardless of whether they are in high school or college.

Recipient #4's Post-Secondary Information

Please enter recipient #4's collegiate information.
College Address
College Address
Line 1
Line 2
City
State/Province
Zip/Postal

Recipient #4's Demographic Information

Recipient's Gender
Recipient's Race
Recipient's Ethnicity
Was the recipient eligible for free or reduced-price meals in high school?
Was the recipient the first in their family to attend a post-secondary institution to attain a post-secondary credential?
Is the recipient a 21st Century Scholar?

Confirm These Two Numbers Match

$

$
I confirm that the Cumulative Amount For Recipients 1-4 is the same as the Total Amount For ALL Recipients