{"content":[{"text":"VERIFICATION OF INCOME ELIGIBILITY \n When applying for a scholarship, Portland Parks & Recreation requires a copy of your latest 1040 \n Income Tax Form or other accepted form to verify your income (see below). This information must be \n update with each subsequent scholarship request. Portland Parks & Recreation values your privacy \n and will make every effort to ensure information provided remains confidential.","bbox":{"left":0.058824,"top":0.092092,"width":0.882749,"height":0.10812000000000001}},{"text":"Number of children living at home: ___________Number of adults in household: __________","bbox":{"left":0.058824,"top":0.21447,"width":0.814431,"height":0.020818000000000003}},{"text":"TOTAL YEARLY FAMILY INCOME (include child support if applicable):","bbox":{"left":0.058824,"top":0.266818,"width":0.6545719999999999,"height":0.020863999999999994}},{"text":"� 0 to $23,107 \n � $23,108 to $31,283 \n � $31,284 to $39,460","bbox":{"left":0.117647,"top":0.302576,"width":0.18854900000000002,"height":0.05798500000000001}},{"text":"� $39,461 to $47,637 \n � $47,368 to $55,814 \n � $55,815 to $63,991","bbox":{"left":0.352941,"top":0.302576,"width":0.18854900000000002,"height":0.05798500000000001}},{"text":"� $63,992 to $72,168 \n � $72,169 to $80,345 \n � Over $80,346","bbox":{"left":0.647059,"top":0.302576,"width":0.18854899999999997,"height":0.05798500000000001}},{"text":"ACCEPTABLE forms of income verification (please check form used):","bbox":{"left":0.058824,"top":0.392045,"width":0.609179,"height":0.02096999999999999}},{"text":"_____Most recent 1040 income tax return \n _____Proof of current Social Security benefits (SSA Benefit Statement or SSA-1099) \n _____Proof of disability pay (SSI) \n _____Proof of current OHP (Oregon Health Plan) eligibility \n _____Oregon Trail (food stamps) award letter","bbox":{"left":0.058824,"top":0.426894,"width":0.7357450000000001,"height":0.09051500000000001}},{"text":"UNACCEPTABLE forms of income verification \n • Bank Statements \n • Paycheck stubs \n • Individual W-2’s \n • Plastic Oregon Trail Card \n • WIC","bbox":{"left":0.058824,"top":0.548863,"width":0.406392,"height":0.11309100000000005}},{"text":"To the best of my knowledge, the information provided on the Verification of Income Eligibility form is \n accurate. I understand that misrepresenting could result in an inability to receive Portland Parks & \n recreation scholarships in the future.","bbox":{"left":0.058824,"top":0.693409,"width":0.872163,"height":0.05566599999999999}},{"text":"Signature of Participant (18 & older or Parent/Guardian)","bbox":{"left":0.139804,"top":0.783561,"width":0.484178,"height":0.020818000000000003}},{"text":"Date","bbox":{"left":0.764706,"top":0.783561,"width":0.04149000000000003,"height":0.020818000000000003}},{"text":"FOR OFFICE USE ONLY","bbox":{"left":0.07451,"top":0.836847,"width":0.18673299999999998,"height":0.017317000000000027}},{"text":"After review by staff, proof of eligibility was:","bbox":{"left":0.07451,"top":0.865943,"width":0.31213,"height":0.017028000000000043}},{"text":"� \n �","bbox":{"left":0.103902,"top":0.896761,"width":0.009781999999999999,"height":0.03798099999999993}},{"text":"Returned to customer \n Shred","bbox":{"left":0.13331,"top":0.895885,"width":0.157185,"height":0.03985300000000003}},{"text":"Date: ______________ Staff Name: ____________ \n Date: ______________ Staff Name: ____________","bbox":{"left":0.309774,"top":0.895885,"width":0.37607199999999996,"height":0.03985300000000003}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}