"Sfm Foundation Scholarship Application"


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SFM Foundation Scholarship
Scholarship guidelines
Basic eligibility requirements
Expectations of scholarship recipients
n Must be the natural, adopted, step-child or full dependent
n Provide proof of enrollment for each semester at
of a worker injured or killed in a work-related accident
participating educational institution.
during the course and scope of employment with a
n Must submit official grade report at the end of each
Minnesota-, Wisconsin-, or Iowa-based employer and
completed semester/term.
entitled to receive benefits under the Minnesota Workers’
n Must maintain satisfactory grades of a cumulative “C”
Compensation Act, Worker’s Compensation Act of
average or higher and stay continuously enrolled with at
Wisconsin, or Iowa Workers’ Compensation Act.
least 12 credits.
n Must be a Minnesota, Wisconsin or Iowa resident between
n Prompt response to requests from the SFM Foundation for
the ages of 16 and 25 at the time of the application.
documents, school invoices, grade reports, etc.
n Must have a high school diploma, GED or be a high school
n Prompt notification of dropped classes or withdrawal from
student in good standing. Academic achievement, aptitude,
extracurricular activities, and community service of the
applicant is considered.
n Cooperation in responding to requests to attend SFM
Foundation functions such as fundraising events, seminars,
n Grade point average will be reviewed against the number
etc. (Attendance is not required, but we encourage
of hours the applicant works and his/her community
students to be willing to appear on our behalf.)
n Must be pursuing a primary college or university degree
Uses of scholarship
(bachelor’s or associate’s) or vocational education and
n Tuition, books, and fees (excludes room and general living
training (certificate or license) from any accredited school.
n Must demonstrate financial need.
n Scholarship funds will be paid directly to the educational
institution in two equally apportioned installments during
the school year (timing may vary by school).
n Amount awarded may range between $1,000 and
n Scholarships are awarded annually each spring.
Scholarship applications must be received by SFM
Foundation by March 31.
SFM Foundation is a non-profit organization created to administer a scholarship program to benefit
children of workers injured or killed in work-related accidents. SFM Foundation is an affiliate of
SFM Companies, a regional workers’ compensation insurance group with headquarters in Bloomington,
Our mission is to assist deserving students who have been affected by a parent’s work-related injury
regardless of who the insurer was at the time of injury. All applications are graded independently
regardless of the applicant’s insurer.
SFM Foundation Scholarship Application | 2
SFM Foundation Scholarship
Application form
Please send completed application form and
documentation listed under “Additional documents you need to provide,” page 7, to the following: SFM
Foundation, P.O. Box 582992, Minneapolis, MN 55458-2992. Fax (952) 838-2055. Telephone (855) 621-2076. Email info@sfmfoundation.com.
This application information and form may be downloaded at www.sfmfoundation.com/application.pdf.
I. Applicant information
Please print clearly
Name (last, first, middle)
Street address, city, state, zip
Daytime telephone No.
Student cell phone No. and cell carrier provider (ex. Verizon, Sprint, AT&T)
Date of birth
Social Security No.
Email address
Mother’s name
Father’s name
Current grade in high school or college (10th, 11th, 12th, etc.)
Do you know or are you related to anyone at SFM Mutual Insurance Co. or its
How did you learn about SFM Foundation?
subsidiaries? If so, please indicate who and the relationship.
II. Information regarding injured or deceased parent or legal guardian
A. Identification of injured or deceased parent or legal guardian
Full name of injured or deceased parent or legal guardian
Social Security No. of injured or deceased parent or legal guardian
Date of injury or death
Worker Identification No. (WIN) (if available)
Address of parent or legal guardian (if applicable)
Telephone No. of parent or legal guardian (if applicable)
Nature and extent of parent or legal guardian’s injury (attach additional
How has this injury affected you or your household (attach additional sheet if
sheet if necessary)
B. Parent’s or legal guardian’s employer at time of injury/death
Employer of parent or legal guardian at time of work injury
Employer address
Employer telephone No.
Employer workers’ compensation administrator name
C. Workers’ compensation insurance company information
Name of insurer
Insurer address
Insurer telephone No.
Insurer email
Claims representative name
Insurer claim No.
Is this injury admitted or denied by the insurer
D. Attorney representing injured or deceased parent or legal guardian (if applicable)
Name of attorney
Name of attorney firm
Attorney address
Attorney email
Attorney telephone No.
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III. Applicant’s academic background
A. High school
Name of high school
Address of high school
Extra-curricular school and community activities
Current cumulative GPA (attach documentation)
ACT or SAT score
Class rank
B. College already attended (if applicable)
Name of college
Address of college
Extra-curricular school and community activities
Current cumulative GPA (attach documentation)
C. Future plans for college (for which you will use this scholarship). Note: Please attach documentation verifying college acceptance (see page 7, item 8).
Type of education (4-year degree, 2-year degree, vocational school, other)
Date accepted and date you plan to begin
Name of college
Address of college
Career objective
Major field of intended study
Annual tuition
Will you be a commuter student or live on campus?
Other types of scholarships you have applied for
Scholarships or financial aid you have already been awarded
If you will be employed during your college career, please indicate type of
List all schools you have been accepted to for admission
work, how many hours per week and average amount earned per academic
Expected graduation date
Any other information you feel we should consider. (Attach additional sheet if necessary.)
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IV. Household financial information
(Note: Household is defined as the residence wherein the injured parent or legal guardian lives or lived at the time of injury.)
As an alternative to completing page 5 of the SFM Foundation application regarding financial information, you may
attach a completed FAFSA form if available.
All financial information should be based on most recent available tax records at
time of application.
A. Parental information
What was your parents’ adjusted gross income?
Annual amount of child support paid because of divorce or separation or as a
result of a legal requirement.
Adjusted gross income is on IRS form 1040 line 37; 1040A line 21; or 1040EZ line 4.
Enter the amount of your parents’ income tax.
Your parents’ number of family members in most recent tax year.
Income tax amount is on IRS Form 1040 line 56; 1040A line 35; or 1040EZ line 44.
Include in your parents’ household: (1) your parents and yourself, even if you don’t live with your
parents, (2) your parents’ other children if your parents will provide more than half of their support.
How many people in your parents’ household will be college students when you enroll?
Always count yourself. Do not include your parents. Include others only if they will attend, at least half-time in a program that leads to a college degree or certificate.
B. Parent asset information
As of today, what is your parents’ total current balance of cash, savings and
In the current year or one year prior, did you or anyone in your household
checking accounts?
receive benefits from any of the benefits programs listed? Mark all the
programs that apply.
 Social Security Income $
As of today, what is the net worth of your parents’ investments, including real
estate (not your parents’ home)?
 Work Comp Settlement or payments $
 Disability Insurance Payment $
As of today, what is the net worth of your parents’ current businesses and/or
 Welfare $
investment farms?
Child support received for all children.
C. Student finances
What was your adjusted gross income?
Enter the amount of your income tax.
Adjusted gross income is on IRS Form 1040 line 37; 1040A line 21; or 1040EZ line 4.
How much did you earn from working in most recent tax year?
Grant and scholarship aid reported to the IRS in the adjusted gross income.
Answer the question whether or not a tax return was filed. This information may be on the W-2
forms, or on IRS Form 1040 lines 7 + 12 + 18 + Box 14 of IRS Schedule K-1 (Form 1065);
1040A line 7; or 1040EZ line 1.
D. Student asset information
As of today, what is your total current balance of cash, savings and checking
As of today, what is the net worth of your investments, including real estate
(not your home)?
E. Other information
Is any member of your household currently a plaintiff/claimant in a lawsuit
Money received, or paid on your behalf, not reported elsewhere on this form.
from which additional income or settlement may be awarded? If so, please
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