Application for Scholarship Assessment

IMPORTANT: This form, along with pay slips and Notice of Assessment (NOA) should be uploaded to your online application.
Note: Use the ‘ctrl’ key to upload multiple files in your online application.

Student details:

Student ID:
First name (s):	Family name:
Mailing address:
Scholarship or grant applying for:

Household / family income:

The following table helps us to determine your circumstances. You must complete this table in order to have your application for a scholarship or grant assessed. Do not leave this table blank.

To complete the table, please provide details in the relevant fields for every member of your household, including the following:

Yourself

Spouse (if you are in the same household)

Parents / Guardians (if you are in the same household)

Siblings / Children / Dependents (if you are in the same household) (regardless of their age or income)

Note: If one of the above persons does not earn an income, please put a $0 in the income fields.

Note: You do not need to list housemates or parents if you are financially independent from them.

First name	Surname	Date of birth	Relationship to applicant	Total annual taxable income (previous financial year)	Expected annual taxable income (current financial year)

Supporting documentation:

We also require a copy of the following for each person that contributes to your household income.

Note: You do not need to provide documents for housemates or parents if you are financially independent from them.

Please upload the following in your online application form when you upload this completed Assessment Form:

Most recent employer pay slip

and

Most recent Notice of Assessment (NOA) or Income Tax Return (ITR) from the Australian Tax Office (ATO)

Note: Use the ‘ctrl’ key to upload multiple files within the online application.

Additional Information to support your application:

Applicant declaration: Please read carefully, tick all boxes, sign and date the declaration

I have answered all questions honestly
I have supplied and attached ALL information which may affect how my circumstances or financial situation are assessed or perceived, including copies of:
Most recent employer pay slip for each person that contributes to your household income, including yourself (excluding housemates or parents if you are financially independent from them)
AND
Most recent Notice of Assessment (NOA) or Income Tax Return from the Australian Tax Office for each person that contributes to your household income, including yourself (excluding housemates or parents if you are financially independent from them) Use the Use the ‘ctrl’ key to upload multiple files within the online application.
I have not omitted ANY information which may affect how my circumstances or financial situation are assessed or perceived
I declare that the information I have supplied about my circumstances is true and complete and acknowledge that should this information be found to be incorrect, any scholarship or grant awarded to me may be withdrawn.
I understand that by submitting supporting documentation, UniSA may contact the issuer of the document to confirm its authenticity
I will retain an original copy of all supporting documentation and will be able to provide this if requested
I understand that: Giving false or misleading information is a serious offence under the Criminal Code (Commonwealth)

Submitted by:	Submitted date: