Recipient Request Form
For Payment of Scholarship

	If you are the recipient of a scholarship awarded by the Baraboo Community Scholarship Corporation (BCSC) please complete this Request for Payment Form and mail it along with your proof of enrollment and current class schedule to:

BCSC
P. O. Box 380
Baraboo, WI  53913-0380
	
	We will accept reimbursement requests beginning on July 1 for first semester payments.  Please submit second semester requests after your enrollment paperwork is complete for the second semester.  All reimbursement requests must be submitted by February 15 each year.

	If you have any questions, contact BCSC at barabooscholarships@gmail.com.

REQUEST FOR SCHOLARSHIP PAYMENT	
Name:       	
Address:       	
City:       	State:       	Zip:       	
Name of School Attending:       	
School Payment Mail Address:       	
(school mail address con’t):      	
(school mail address con’t):      	
(school mail address con’t):      	
Student ID #:       	
Student Phone number:       	
Student e-mail address:       	
Please list all BCSC Scholarships Awarded and Dollar Amounts:	
Name of Scholarship	Dollar Amount	
1.       	$      	
2.       	$      	
3.       	$      	
4.       	$      	
Please enclose official proof of registration (tuition bill/receipt and schedule showing current classes and credit load) from your school and mail to: BCSC, P.O. Box 380, Baraboo, WI  53913-0380 after July 1 for first semester payment or after December 1 for second semester payment.	

	I attest that I am officially enrolled in a qualifying school for the above scholarship(s) and request immediate reimbursement.

									       
		______________________________________  ______________
		Signature						  Date