Enclosure: Application Form for Recognition of Students with Family Financial Disabilities (Sample Form) School: Department: Major: Grade: Class: Basic situation Home Communic ation Informatio n Full na me Date of birth Gend er ID car d No. Family populatio n Nativ e place Phone number Detailed address Postal Code Family Membership Full na me Ag e Parent Mobile Number And students relationship Work (study) unit Occupati on Annu al inco me (yuan ) Healt h Students from poor families with archived lika:_Yes_No; Minimum Living Security Family Students: Yes_No; Special group types Extremely poor support students:_Yes_No; students: Yes_No; Martyr's children: Yes_No; Orphan and disabled Disabled students with family financial difficulties and children of disabled persons:Yes, No. Influencing the family economy Statusrelated informatio n Per capita annual household income is RMB. Families suffering incidents: from natural disasters:Families suffer unexpected Family members due to disability, old and weak ability to work: Unemployment of family members:Family debt situation: Other information: Commitment: Personal commitment Signature by student himself (or guardian) Note: 1. This form can be used to identify students with financial difficulties and can be copied. 2. Schools, departments, majors, grades and classes can be filled in selectively according to the actual situation. 3. Commitment content should be manually filled out by myself. "I promise that the above information is true. If it is false, I will bear the corresponding responsibility."

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