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Parent/Guardian signature Family s yearly Income Name of childAge Address Street City St Zip Phone Home - Work - Cell - Email Income level information based on 2009 Federal Poverty Guidelines Illinois Medicaid Eligibility and 2008 Census. CERTIFICATION FOR SCHOLARSHIP CONSIDERATION TO BE COMPLETED BY THE PARENT/GUARDIAN Please circle the number of individuals including adults in your family/household and the income level for the household. FAMILY SIZE OF PERSONS INCOME LEVEL 60 052 or more 19...
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