MARYJANE CARR SCHOLARSHIP FUND RECIPIENT INFORMATION FORM ‘Administered by FirstMerit PrivateBank 100 E. Michigan Avenue, Suite 200, Jackson, Mi 48204 Phone: 617.788.2772 Fax: 517.788.2776 TO BE COMPLETED BY STUDENT RECIPIENT: vane: Filey Uoniel Anthony q Tast First Middle! High Schoo!: Home Address: Social Security Number: College You Plan to Attend: Dyes who Do you have @ financial need for this scholarship (Annual family adjyst€@ gross income (AGI) as reported cn income taxes of $80,000 or less): es TINo ‘Are you or your family an enifloyee of FirstMerit Bank, N.A.? Grade Point Average (must be 25 or higherto qualiy;; 2° __ATTAGH TRANSCRIPT {understand that any intentional falsification of any of the statements made in this from any further consideration. — Ba Parent/Guardian Signature if Applicant under 18 Date TO BE COMPLETED BY HIGH SCHOOL: hereby recommends the above student to receive a scholarship Namie of High Schoo! in the amount of $1,160 from the Maryjane Carr Scholarship Fund. Date Printed name & tle of person signing on behaif of school Phone Number: