Scholarship Payment Request Form

Foundation for Delta Educational and Economic Development

Scholarship Payment Request Form

Participant's Full Name

First

Middle

Last

Address (to mail payment)

Street/P.O. Box

City

State

Zip Code

Email Address

Cell Phone

Home Phone

Please provide information regarding the college, university, or vocational school you plan to attend for the 2021 summer or fall term and attach verification documents:

Name of Institution

Location

Summer/Fall Term Start Date

Major/Concentration

Documents provided to verify admission and enrollment (two documents required):

Official letter of admission from the institution you plan to attend

Document certifying your housing assignment or payment of housing fees

Document certifying enrollment/registration or payment of enrollment/registration fees

Upload Document 1

Upload Document 2

REQUEST AND ACKNOWLEDGMENT

Based on the verification provided, I request payment of the following amount in scholarship funds, as identified in my award letter for Cotillion 2022:

I hereby submit documentation to verify my admission and enrollment in the institution listed above. I acknowledge that the scholarship funds will be disbursed by check and sent to my mailing address, as provided above.

Signature of Participant (required)

Date

Signature of Parent (required)

Printed Name of Parent

Submit above information and documents by September 30, 2022