Pittsburgh Chess Club
Financial Aid Request Form

Thanks to the Grable foundation, limited financial aid is available for students who would otherwise have difficulty affording the cost of Pittsburgh Chess Club scholastic chess tournaments or classes. In order to qualify, your annual gross family income must fall under the income limits listed below or you must be facing some short-term situation that suggests financial hardship.

If approved, your child pays only $5 to play in a chess tournament or $10 for Pittsburgh Chess Club classes. US Chess Federation membership is free if needed to participate in one of the above.

Which discount(s) are you applying for? Class____ Tournament____ US Chess Federation membership____

Child's name _________________________________________________________________________
Street Address_________________________________________________________________________
City__________________________State____________________Zip_____________________
School_________________________________________Grade_________ Phone __________________

Annual Gross Family Income $_____________ (use figure from last year's tax return, if filed)
Number of Adults in Family ______ Number of children in Family ______

			Family Size 					Income Limits
(Includes adults & children claimed as dependents)
			2						$17,797
			3						$22,321
			4						$26,845
			5						$31,369
			6						$35,693
			7						$40,417
			8						$44,941
			9 or more					$49,465

If your income is above the limits shown, please indicate other form of financial hardship:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Parent's (or guardian's) name (printed)_________________________________________ Date__________

Parent's (or guardian's) name (signed)_________________________________________________

Please mail together with the front page of your latest federal tax return. It is only necessary to mail the tax return with this form once per year.