WARNING: It is an offence under the Criminal Code (WA) to knowingly or recklessly give materially false or misleading information in order to obtain a financial advantage.
I 		, 		
	(Full Name of parent)		(Occupation of parent)	
of					
	(Home address)			
State that to the best of my information knowledge and belief:
The total gross income of my family (my spouse/partner, my dependents and myself unless otherwise explained below was:	
	Year	Amount	
Last Financial Year:		$	
The Previous financial year to the one above		$	
The number of people financially dependent on the abovementioned income/s (spouse, children other family members and myself):		
The age/s of the dependent child/children (student/s) are:		

Members of my family have the following investments (if you have no other investments please enter 0.00 as the dollar amount):	
Investment Properties to the value of:	$	
Share Portfolio to the value of:	$	
Other Investments to the value of:	$	
and	
I wish to provide the following additional information:	

DECLARATION:  The information provided above is true and complete in every particular and I have not withheld any information that I believe is relevant to the eligibility or otherwise of my son/daughter for a scholarship, the subject of this application.	

(Signature)		(Date)	
			
Office use only			
Average Income:				Total Investments: