LEF Foundation Fellowship Application
Financial Statement |
The purpose of the LEF Foundation Fellowship is
to provide access to The Writers' Room of Boston, Inc., to writers who cannot
afford the membership fees. The award is based on both the quality of the applicant's
project and financial need. Therefore, the evaluation committee needs to know
the financial status of applicants. Please complete this form and enclose it
in a separate sealed envelope with the rest of your application. This information
is confidential and will be destroyed once the fellow is selected for the coming
year.
Print, complete, and mail this form with your LEF application materials.
Candidate's Last Name, First Name, and Middle Initial
Candidate's Home Address (Street) (City) (State) (Zip Code)
Home Telephone: ( )_________________________
Social Security #___________________ Gender: Male_____ Female_____
Other Members of the Family who are Dependents (Living at Home) Age
Applicant's Occupation:_____________________________ Annual Income:
____________
Spouse's Occupation:_______________________________ Annual Income:
____________
Real Estate Owned:___________________________________________________________
Other Assets (bank accounts, securities, etc.): _______________________________________
Indebtedness (mortgage, outstanding obligations, etc.): ________________________________
Special Family Circumstances: ____________________________________________________
The foregoing statements are true to the best of my knowledge and belief.
Signed_______________________________ Date:__________________
