Form 990,pF Return of Private Foundation - Charity Blossom

L/

.4-/-E .Form 990,pF Return of Private Foundation OMB No 1545-0052

or Section 4947(a)(1) Nonexempt Charitable TrustD Treated as a Private Foundationepartment of the TreasuryInternal Revenue servlet. Note. The foundatlon may be able to use a copy of this return to satisfy state reporting requirements.

For calendaryear 2009, ortax year beginning ,and endingG Check all that apply M Initlal return IJ lnitlal return of a former public charity M Flnal return

lj Amended return 1:1 Address change Z1 Name changeuse me ,RS Name of foundation A

I b I.Othtarviiise, LAR.A ABBOTT FOUNDATION

Employer identification number

3 6 - 6 0 6 9 6 3 2prim Number and street (or P O box number if mail is not delivered to street address) Room/surte B

of WW- 1 5 0 5 WHITE OAK DRIVETelephone number847-935-5801

213335336 Crty or town, state, and ZIP code" AUKEGAN, IL 60085

H Check type of orgamzatlon: I,X,l Sectlon 501(c)(3) exempt private foundatlon

1:1 Sectlon 4947@)-(1) nonexempt charltable trust rj Other taxable prlvate foundatlon El Fair market value of all assets atend of year .1 Accounting method: LX1 Cash I-I Accrual

(from Pan //, co/. (C), /me 16) II other (specliy) F

If exemption application is pending, check here1- Foreign organlzatlons, check here PIII2, Foreign organizations meetrng the 85% test,check here and attach computation , lj

lf private foundatlon status was terminatedunder secnon so7(b)(1)(A), cheek here PIIIlf the foundation is ln a 60-month terminatlon

under sectlon 507(b)(1)(Bl, check here 21:1I 5 2 1 2 I 0 7 1 I 3 3 0 . (Part /, co/umn (d) must be on cash bas/s.)I Part I I Analysis of Revenue and Expenses (a) Revenue and (b) Net Investment

f.Ta1lZL".l$Yf.".TlZl?$i ZATJKTLTE (22lSf1"$fI.T)(") may ""1 expenses ner books IncomeI1) Disbursements(c) Adlusted net (

Income f.11fr*eg*:.::Lrsf*e1 Contrlbutions, grfts, grants, etc., recelved 6 8 , 0 6 2 . N/A2 Check ) lj lfthefnundabon is not requlred to attach Sch B

Interest on savings and temporary3 cash investments

4 Dividends and interest from securitles 5 , 9 40 , 748 . 5 , 9 40 , 748 . ETATEMENT 15a Gross rents

b Net rental income or (loss)

68 Net gain or (loss) from sale of assets not on line 10 5 , 8 2 4 , 7 2 7 - 5

UB

b f.fZ.s?.s.?.l1T."2""a? "" 3" 2 0 5 . 7 6 4 (4320 1 31-5,,-5

Q19.

7 Capital galn net income (from Part IV, line 2) 0 .

E

A

8 Netshort-term capltal gain 1 P* l I

0

9 Income modlflcations

Il

Gross sales less retums103 and allowances ---Ilia4.

AUG

0 Less Cost of goods sold

c Gross profit or (loss)

i U ,Ig .U11 Other Income

0

12,451. 12,451. STATEMENT 2

E

e neinenermmnnn k29,ao3,466.b 5,953,199.

Infl

13 363,872. 36,387.Compensation of officers, directors, trustees, etc 327,485.

AN

14 Other employee salaries and wages 584,763. 9,356. 575,407.15 Pensron plans, employee benefrts 2 7 0 , 0 6 9 . 1 9 , 3 4 3 . 250 ,726.

E%3DSE

16a Legal fees STMT 4 , 3 1 0 .b Accountmg fees STMT 3 4 , 0 0 0

Pe

0. 0.o on on345

eEx

c Other professronal fees STMT 141,600. 141,600. 0.17

18

Interest

Taxes

atv

STMT 6 (1o2,375.b o. o.

"str

19 Depreclatlon and depletion 3 3 , 9 2 6 . 0 .20

21

Adm n

Occupancy

Travel, conferences, and meetmgs 3 6 , 4 6 2 . 0 . 36,462.22

23

Prmtrng and publrcations

Other expenses STMT

g and

7 3,315,465. 0. 3,314,866."" 24

perat n

Total operating and administrative

expenses. Add Innes 13through 23 4 , 682 , 092 . 206 , 686 . 4,504,946.

0

25 Contrlbutions, gifts, grants pald 9,302,757. 9,302,757.26 Total expenses and disbursements.

Adannes24ami25 13,984,849. 206,686. 13,807,703.27 Subtract llne 26 from lrne 122

8 Excess of revenue over expenses and disbursements 1( 4 3 , 7 8 8 , 3 1 5 - P

b Net investment income trfneoatwe. enter-0-) 5 , 7 4 6 , 5 13 .C AdiI.lSfed D81 IIICOTTIB Gt negative, enter -0-) N/A

32352.10 LHA For Privacy Act and Paperwork Reduction Act Notice, see the instructions. ppm 990-PF (zoos)1 is10060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

I - 3F0011 990-PF (2009) CLARA ABBOTT FOUNDATION 3 6 - 6 0 6 9 6 3 2 P309 2

Bal nee Sheets Attached schedulesandamountsln the descrlptlon Beginning Of Veal End 01 yeara"mm" 5"""" ""0" """*"1""m"""S 0"" (a) Book Value (b) Book Value (c) Fair Market Value

-A

Cash - non-interest-bearing

NI

Savings and temporary cash investments 1,393,386. 1,615,760. 1,615,760.Accounts receivable P

Less: allowance for doubtful accounts P

ID

4 Pledges receivable PLess: allowance for doubtful accounts P

5 Grants receivable

6 Receivables due from officers, directors, trustees, and other

disqualified persons7 0Ultln01C5 3l*ldl0il*lSr8C8lV3bIl ,

Less: allowance for doubtful accounts P

Assets

8 Inventories for sale or use

9 Prepaid expenses and deferred charges10g Investments - U.S. and state government obligations

b Investments - corporate stock STMT 8 200,312,684. 156,355,373. 210,292,001.c Investments - corporate bonds

11 Investments -land, bulldings,and equlpment basls P

Less accumulated depreciation P12 Investments - mortgage loans13 Investments - other

14 Land, buildings, and equipment: basis P 2 , 42 4 , 42 5 .Lessmiimiilateifdeinieclallitn P 2,260,856. 218,072. 163,569. 163,569.15 Other assets (describe P )

16 Total assets (to be completed by all filers) 201,924,142. 158,134,702. 212,071,330.17 Accounts payable and accrued expenses

-AQ

Grants payable

L"ab" "I

I9 ISI N3 -BN) -A Q @

Deferred revenue

Loans from officers, directors, trustees, and other disqualified persons

Mortgages and other notes payable

Other liabilities (describe b )

ES

23 Total liabilities (add lines 17 through 22) 00 ofFoundations that follow SFAS 117, check here P Mand complete lines 24 through 26 and lines 30 and 31.

24 Unrestricted

ESIIC

25 Temporarily restricted

26 Permanently restrictedFoundations that do not follow SFAS 117, check here P DLIand complete lines 27 through 31.Capital stock, trust principal, or current funds

s or Fund Ba a&Nl

etN)@

Paid-in or capital surplus, or land, bldg., and equipment fund762,767. 762,767.0. 0.

AssINDID

Retained earnings, accumulated income, endowment, or other funds 201,161,375. 157,371,935.

Net

30 Total net assets or fund balances 201, 924,142 . 158 , 134,702 .

31 Total liabilities and net assets/fund balances 201, 924,142 . 158 , 134,702 .Analysis of Changes in Net Assets or Fund Balances1 Total net assets or fund balances at beginning of year - Part II, column (a), line 30

(must agree with end-of-year figure reported on prior year*s return)2 Enter amount from Part I, line 27a

3 Other increases not included in line 2 (itemize) P

IDN)-I

201 924 142.443 788 315.)

O.4 Add lines 1,2,and3

5 Decreasesnotincluded in line2(itemize) P PRIOR PERIOD ADJUSTMENT

UI#

158 135 827.1,125.

6 Total net assets or fund balances at end of year (line 4 minus line 5)- Part ll, column (Q), line 30

OD

158,134,702.92351102-02-10

10060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION

Form 990-PF (2009)

ABBOCLA1

U Part IV Capital Gains and Losses for Tax on Investment Income

(a) List and describe the kmd(s) of property sold (e.g., real estate, (b?,l"fff,I*f)rag)$a"s*(f)ed (ce Date acquired (d) Date sold2-story brick warehouse: or common stock, 200 shs. MLC Co.) D . Dommon 010-. day. YI-) (F00-1 GGY. YI-)

I

(f) Depreciation allowed (g) Cost or other basis (h) Gain or (loss)(8) Gross Sales price (or allowable) plus expense of sale (e) plus (f) minus (g)

Irlfm ego-Pfyooe) CLARA ABBOTT FOUNDATION 3 6 - 6 o 6 9 6 3 2 Page a

-A@2933

SEE ATTACHED STATEMENT

09.055

205,764,432. 241,589,159. 435,824,727.)Complete only for assets showing gain in column (h) and owned bythe foundation on 12/31/69 (I) Gains (C0), (I1) gam mmus- Ad t db k E f L col. (k), but not less than -0-) or(I) F-M-V- 35 of 12/31/59 (1215 ofu1S2731/693 (ol/e:?:31s(8, itfoang/I) Losses Umm col" (nn

0D.nU"H

435,824,727.)If gain, also enter in Part I, line 7

2 Capital gain net income or (net capital loss) lf (loss), enter -0- in Part I, line 7 2 43 5 , 8 2 4 , 7 2 7 . )3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):

If gain, also enter in Part I, line 8, column (c).If (loss enter -0- in Part I, line 8 ) 3 N/APart V Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income

(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)

If section 494O(d)(2) applies, leave this part blank.

Was the foundation liable for the section 4942 tax on the distributable amount of any year inthe base period? lj Yes III NoIf "Yes," the foundation does not qualifv under section 4940(g). Do not complete this part.1 Enter the appropriate amount in each column for each year, see instructions before making any entries."I ibi ici "IB d . D st b ton ratio

Calendar yeaa,Sf0P?g,?ye%$ag2g,nn,ng m) Ad )usted qualifying distributions Net value of noncharitable-use assets (co), (bl) J:V,%$d by C0), (3))2008 17,324,485. 221,320,031. .0782782007 16,274,948. 258,926,661. .0628552006 15,776,106. 252,308,963. .0625272005 17,473,337. 246,837,895. .O707892004 20,282,877. 242,636,062. .0835942 Toiaiofiine1,coiumn(a) 2 . 3580433 Average distribution ratio for the 5-year base period - divide the total on line 2 by 5, or by the number of years

the foundation has been in existence if less than 5 years 3 . 0 7 1 6 0 94 Enter the net value of noncharitable-use assets for 2009 from Part X, line 5 4 1 8 2 , 0 9 9 , 5 1 3 .

5 Multiplyline4byIine3 5 13,039,964.6 Enter 1% of net investment income (1% of Part I, line 27b) 6 5 7 , 4 6 5 .1 Addiinessande 7 13,097,429.8 Enter qualifying distributions from Part XII, line 4 B 1 3 , 8 O 7 , 7 0 3 .

If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate.See the Part Vl instructions.923521 oz-oz-io Form 990-PF (2009)

310060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

U IF000 990-PF (2009) CLARA ABBOTT FOUNDATION 3 6 - 6 0 6 9 6 3 2 P896 4I Part VI I Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948 - see instructions)

1a Exempt operating foundations described in section 4940(d)(2), check here P I-I and enter "N/A" on line 1.

Date of ruling or determination letter: (attach copy of letter if necessary-see instructions)b Domestic foundations that meet the section 4940(e) requirements in Part V, check here P III and enter 1% 1 5 7 , 4 6 5 .

of Part l, line 27b

c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part l, line 12, col. (b)

Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)Aaaiinesiandz 57,465.Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)

Tax based on investment income. Subtract line 4 from line 3. lf zero or less, enter -0- 5 7 , 4 6 5 .Credits/Payments:

a 2009 estimated tax payments and 2008 overpayment credited to 2009 6a 1 2 5 0 0 O .b Exempt foreign organizations - tax withheld at source Mc Tax paid with application for extension of time to file (Form 8868) M 4 5 0 0 0 .d Backup withholding erroneously withheld mTotal credits and payments. Add lines 6a through 6d 1 7 0 , 0 0 0 .

8 Enter any penalty for underpayment of estimated tax Check here IE if Form 2220 is attached9 Tax due. lf the total of lines 5 and 8 is more than line 7, enter amount owed

10 Overpayment. lf line 7 is more than the total of lines 5 and 8, enter the amount overpaid P 10 1 1 2 , 5 3 5 .11 Enter the amount of line 10 to be: Credited to 2010 estimated tax P 1 1 2 , 5 3 5 .I Refunded P 11 0 .

I Part Vll-A I Statements Regarding Activitiesta During the tax year, did the foundation attempt to influence any national, state, or local legislation or did it participate or intervene in YES N0any political campaign? 1a Xb Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see instructions for definition)? 1b X

/fthe answer is "Yes " to 15 or 1b, attach a detailed descnption of the activities and copies of any materials published ordistnbuted by the foundation in connection with the activities.

c Did the foundation file Form 1120-POL for this year? 1c Xd Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:

(1) On the foundation. P S O . (2) On foundation managers. P S 0 .e Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed on foundationmanagers. P $ 0 .

2 Has the foundation engaged in any activities that have not previously been reported to the IRS? 2 XIf " Yes, " attach a detailed description of the activities

3 Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles of incorporation, or

bylaws, or other similar instruments? /f "YES, " 23260 6 C0f1f0fm6d COPY Of me C/730995

4a Did the foundation have unrelated business gross income of $1,000 or more during the year? Xb lf "Yes," has it filed a tax return on Form 990-T for this year? N/ A

5 Was there a liquidation, termination, dissolution, or substantial contraction during the year?if "Yes," attach the statement required by General Instruction T.

6 Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:0 By language in the governing instrument, or

0 By state legislation that effectively amends the governing instrument so that no mandatory directions that conflict with the state lawremain in the governing instrument? 6 X7 Did the foundation have at least $5,000 in assets at any time during the year? 7 X

lf "Yes," complete Part II, col. (c), and Part XV.

8a Enter the states to which the foundation reports or with which it is registered (see instructions) PIL

mcnawiu

mason

O OI I

:Jigga

N N

b lf the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney General (or designate)

of each State as required by General lnstmction G? If "No," attach explanation ab X9 ls the foundation claiming status as a private operating foundation within the meaning of section 4942(1)(3) or 4942())(5) for calendar

year 2009 or the taxable year beginning in 2009 (see instructions for Part XlV)? /f "Y@S. " COFHP/Sie P-iff X/V 9 X10 Did anypersons become substantial contributors during the tax year? if -vas," attach e schedule listing their names and addresses 10 X

Form 990-PF (2009)

92353102-02-10


WI .F0rm 990-PF (2009) CLARA ABBOTT FOUNDATION 3 6 - 6 0 6 9 6 3 2 I Part vii-A I statements Regarding Activities (continued)

11 At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the meaning of

section 512(b)(13)? lf "Yes," attach schedule (see instructions) 11 X12 Did the foundation acquire a direct or indirect interest in any applicable insurance contract beforeAugust 17,2008? X13 Did the foundation comply with the public inspection requirements for its annual returns and exemption application?

Website address P WWW . CLARA . ABBOTT . COM14 The books are in care of P SHEILA RIVERA- FATHALLAH Telephone no. P 8 4 7 - 9 3 7 - 7 8 3 5

Located at P 1 5 05 WHITE OAK DRIVE , WAUKEGAN , IL ZiP+4 P6 0 0 8 515 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 - Check here P I

and enter the amount of tax-exempt interest received or accrued during the year P I 15 I N/ AI Part Vll-B I Statements Regarding Activities for Which Form 4720 May Be Required

File Form 4720 if any item is checked in the "Yes" column, unless an exception applies. Y65 N01a During the year did the foundation (either directly or indirectly):

(1) Engage in the sale or exchange, or leasing of property with a disqualified person? I:I Yes IE No(2) Borrow money from, lend money to, or othenivise extend credit to (or accept it from)a disqualified person? II Yes IE No(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? III Yes EI No(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? IE Yes II No(5) Transfer any income or assets to a disqualified person (or make any of either available

for the benefit or use ofa disqualified person)? III Yes IE No(6) Agree to pay money or property to a government official? (Exception. Check "No"

if the foundation agreed to make a grant to or to employ the official for a period after

termination of government service, if terminating within 90 days.) I3 Yes IZI Nob If any answer is "Yes" to 1a(1)-(6), did any of the acts fail to qualify under the exceptions described in Regulations

section 53.4941(d)-3 or in a current notice regarding disaster assistance (see page 20 of the instructions)? 1b XOrganizations relying on a current notice regarding disaster assistance check here P I:I

c Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts, that were not correctedbefore the first day of the tax year beginning in 2009? 1c X2 Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private operating foundation

defined in section 4942(i)(3) or 4942(i)(5)):

a At the end of tax year 2009, did the foundation have any undistributed income (lines 6d and 6e, Part Xlll) for tax year(s) beginningbefore zoos? III Yes El Nelf "Yes," list the years P , , ,b Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2) (relating to incorrect

valuation of assets) to the year"s undistributed income? (lf applying section 4942(a)(2) to all years listed, answer "No" and attachstatement- see instructions.) N/ Ac lf the provisions ol section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.P , , ,

3a Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at any timeduring the year? SI Yes IZ Nob If "Yes," did it have excess business holdings in 2009 as a result of (1) any purchase by the foundation or disqualified persons after

May 26, 19693 (2) the lapse of the 5-year period (or longer period approved by the Commissioner under section 4943(c)(7)) to dispose

of holdings acquired by gift or bequest, or (3) the lapse of the 10-, 15-, or 20-year first phase holding period? (USS SCNSUU/9 C.

Form 4720, to determine if the foundation had excess business holdings in 2009.) N / A 3b4a Did the foundation invest during the year any amount in a manner that would )eopardize its charitable purposes? 4a X

b Did the foundation make any investment in a prior year (but after December 31, 1969) that could ieopardize its charitable purpose that

had not been removed from (Qpardy before the first day of the tax year beginning in 2009?

2b

4b XForm 990-PF (2009)

923541D2-02-10


Farm seo-PF,(2oo9) CLARA ABBOTT FOUNDATION 3 6 - 6 0 6 9 6 3 2 Page eI Part VII-B I Statements Regarding Activities for Which Form 4720 May Be Required (cvnflnved)

5a During the year did the foundation pay or incur any amount to:

(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? E Yes iii No(2) Influence the outcome of any specific public election (see section 4955), or to carry on, directly or indirectly,any voter registration drive? D Yes Iii No(3) Provide a grant to an individual for travel, study, or other similar purposes? iii Yes Zi No(4) Provide a grant to an organization other than a charitable, etc., organization described in section

509(a)(1), (2), or (3), or section 4940(d)(2)? E Yes El No(5) Provide for any purpose other than religious, charitable, scientific, literary, or educational purposes, or for

the prevention of cruelty to children or animals? E Yes lil Nob If any answer is "Yes" to 5a(1)-(5), did any of the transactions fail to qualify under the exceptions described in Regulations

section 53.4945 or in a current notice regarding disaster assistance (see instructions)? 5b XOrganizations relying on a current notice regarding disaster assistance check here P I: h

c lf the answer is "Yes" to question 5a(4), does the foundation claim exemption from the tax because it maintained

expenditure responsibility for the grant? N/ A lj Yes lj NoIf " Yes, " attach the statement required by Regulations section 53.4945-5(d).

6a Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums ona personal benefit contract? I3 Yes lil Noli Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? 6b X

/I "Yes" to 6b, tile Form 8870.

7a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? E Yes iii Nob lf yes, did the foundation receive any-proceeds or have anv net income attributable to the transaction? N/ A 7h

Information About Officers, Directors, Trustees, Foundation Managers, Hi hlyPaid Employees, and Contractors g1 List all officers, directors, trustees, foundation managers and their compensation.

b Title, and avera e (c) COFTIDSHSHTIOH d 0""f""""""Si0 e Ex ense(3) Name and address hinuis per week devogted (lf not paid, es"J2iied"ei2,",f@L"""s aizcinuni otherto position enter -0-) camperisanun allowances

SEE STATEMENT 9 363,872. 0. 0.

2 Compensation of five highest-paid employees (other than those included on line 1). If none, enter ""NONE.""(b) Title, and average d C0"""*""""5*0 (e) Ex ense

(a) Name and address of each employee paid more than $50,000 hours per week (Q) Compensation "$""l2f,ii"d",$2,,"Q"d"Ia"5 accoung otherdevoted to position compensanun allowancesN/A 0.00 0. 0. 0.

Total number of other employees paid over $50,000 P I 0Form 990-PF (2009)

923551O2-O2-10

610060812 758432 ABBOCLA 2009.0401l CLARA ABBOTT FOUNDATION ABBOCLA1

Wm9%PG%W) CLARA ABBOTT FOUNDATION 36-6069632 WW7Information About Officers, Directors, Trustees, Foundation Managers, Highly

Paid Employees, and Contractors (continued)3 Five highest-paid independent contractors for professional services. If none, enter "NONE."

(a) Name and address of each person paid more than $50,000 (b) Type of service (e) CompensationLUIS HERNANDEZK3366 TREEHOUSE DRIVE, PERRIS, CA 92571 INANCIAL CONSULTING 103,068.WEALTH METRICS, INC. (DAVID NICPON)6421 CARNATION CT, MT PLEASANT, WI 53406 INANCIAL CONSULTING 81,679.ANZELC & ASSOCIATES, INC (DEB ANZELC)2971 PINE HILL DRIVE, MEDINA, OH 44256 INANCIALPARKER COUNSELING AND CONSULTING SERVICES, INC137 LAXTON RD. SUITE 360, LAXTON PROFESSIONAL INANCIAL

CONSULTING

CONSULTING

63,302.

57,454.PABLO MIRANDA - PO BOX 6022 PMB 304 ,CAROLINA, PUERTO RICO, PUERTO RICO 009 INANCIAL CONSULTING 50,867.Total number of others receiving over $50,000 for professional services P 0I Part IX-A I Summary of Direct Charitable Activities

List the foundations four largest direct charitable activities during the tax year. Include relevant statistical information such as thenumber of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses

1EDUCATIONAL GRANTS AND RELATED EXPENSES - 3,040 GRANTS WEREAWARDED WORLDWIDE

6,882,048.2FINANCIAL AID AND RELATED EXPENSES - 689 AWARDS WERE ISSUED

WORLDWIDE3,896,873.

SEDUCATIONAL SEMINARS AND RELATED EXPENSES - 187 FINANCIALEDUCATION SEMINARS WERE GIVEN WORLDWIDE

651,005.4

I Part IX-B I Summary of Program-Related InvestmentsDescribe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount1 N/A

2

All other program-related investments. See instructions.3

Total. Add lines 1 through 3 P 0.

92358102-D2-10

7

Farm 990-PF (zoos)


Formeeo-PFr2009i CLARA Asisofrfr FouNnzvr1oN 36-6069632 PagesMinimum lnV8Stment R9tUl*Tl (All domestic foundations must complete this part. Foreign foundations, see instructions.)

1 Fair market value of assets not used (or held for use) directly in carrying out charitable, etc., purposes:

s Average monthly fair market value of securities 1 9 2 , 2 8 2 , 2 1 8 .b Average of monthly cash balances 3 , 6 2 4 , 9 9 8 .c Fair market value of all other assets4 Toni(aoaiines1a,b,anac) 195,907,216.e Reduction claimed for blockage or other factors reported on lines 1a and1c (attach detailed explanation) I fe I 0 .

Acquisition indebtedness applicable to line 1 assetsSubtractline2fromline1d 195,907,216.Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see instructions) S TMT 1 3 , 8 0 7 , 7 0 3 .Net value of noncharitiible-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4 1 8 2 , 0 9 9 , 5 1 3 .Minimum investment return. Enter 5% of line 5 6 9 , 1 0 4 , 9 7 6 .

Distributable Amount (see instructions) (Section 4942( ))(3) and (1)(5) private operating foundations and certainforeign organizations check here b W and do not complete this part.)

1 Minimum investment return from Part X, line 6 1 9 , 1 0 4 , 9 7 6 .2s Tax on investment income for 2009 from Part Vl, line 5 5 7 , 4 6 5 .

b Income tax for 2009. (This does not include the tax from Part Vl.)c Addlines2aand2b 57,465.Distributable amount before ad iustments. Subtract line 2c from line 1 9 , 0 4 7 , 5 1 1 .Recoveries of amounts treated as qualifying distributions 0 .Auaiinessana4 9,047,511.Deduction from distributable amount (see instructions) O .Distributable amount as adgusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 9 , 0 4 7 , 5 1 1 .

Qualifying Di$tributi0n$ (see instructions)1 Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:

a Expenses, contributions, gifts, etc. -total from Part l, column (d), line 26 1a 1 3 , 8 0 7 , 7 0 3 .b Program-related investments -total from Part IX-B 1b 0 .2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc., purposes 23 Amounts set aside for specific charitable prolects that satisfy the:a Suitability test (prior IRS approval required) 3ab Cash distribution test (attach the required schedule) 3b

4 ouaiiiyiiio distributions. Add lines ia through ab. enter here and on Pan v, line e, and Pan xiii, line 4 4 1 3 , 8 0 7 , 7 0 3 .5 Foundations that qualify under section 4940(e) for the reduced rate of tax on net investmentinoome.Emer1"/. of Pan i, iirie zro 5 5 7 , 4 6 5 .6 Adjusted qualifying distributions. Subtract line 5 from line 4 6 1 3 , 7 5 0 , 2 3 8 .

Note. The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for the section4940(e) reduction of tax in those years.

-A-A-A-AD.OU*D

aauiawm

,-IO

mawro

CJI

ION,SW

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slcnui-Aw?

Form 990-PF (2009)

92357102-02-10


F00" 990-PF (2009) CLARA ABBOTT FOUNDATION 3 6 - 6 0 6 9 6 3 2 P809 9Undistributed Income (see instructions)

1 Distributable amount for 2009 from Part Xl,iine7 9,047,511.2 Undistributed Income, if any, as ot the end of 2000

a Enter amount for 2008 only

b Total for prior years:

3 Excess distributions carryover, it any, to 2009:

ii From 2004 7ii From 2005 4c From 2006 2ii From 2007 3e From 2000 61 Total of lines 3a through e

4 Qualifying distributions for 2009 from. 1 All

450651606566433

Parixii iine4 DS 13 807a Applied to 2008, but not more than line 2a

b Applied to undistributed income of prior

years (Electron required - see instructions)

c Treated as distributions out of corpus

(Election required - see instructions)

d Applied to 2009 distributable amount

e Remaining amount distributed out of corpus

5 Excess distributions carryover applied to 2009(I1 an amount appears In column (d), the same amountmust be shown in column (a))

619448594859015

6 Enter the net total of each column asindicated below:

8 Corpus Add lines 31, 4c, and de Subtract I

b Prior years* undistributed income. Subtractline 4b from line 2b

c Enter the amount of prior years"undistributed income for which a notice otdeficiency has been issued, or on whichthe section 4942(a) tax has been preassessed

ine 5

viously

d Subtract line 6c from line 6b. Taxable

HITIOUHT - S88 ITISTFUCIIOTIS

e Undistributed income for 2008. Subtract line

4a from line 2a. Taxable amount- se

f Undistributed income for 2009. Subtract

lines 4d and 5 from line 1. This amount must

be distributed in 2010

0 IHSIT.

7 Amounts treated as distributions out of

corpus to satisfy requirements impo

section 170(b)(1)(F) or 4942(g)(3)

8 Excess distributions carryover irom

not applied on line 5 or line 7

sed by

2004

9 Excess distributions carryover to 2010.Subtract lines 7 and 8 from line 6a

10 Analysis of line 9:a Excess from 2005

b Excess from 2006

c Excess from 2007

d Excess from 2008

e Excess from 2009

IPUXUJINJIIB

92358102-02-10

651606566433760

448594859 .015

,192

(H) lbl tv) (dl2009Corpus Years prior to 2008 2008

0.

ol

24,708,535.

ol

Ol

0.9,047,511.

4,760,192.00 of29,468,727.

ol

ol

of

0.

0.

0.

7,450,619.

22,018,108.

Form 990-PF (2009)


u , 1mmswerzmm CLARA ABBOTT FOUNDATION 36-6069632 PmewI Part XIVO Private Operating Foundations (see instructions and Pan vii-A, question 9) N /A

1 a lf the foundation has received a ruling or determination letter that it is a private operating Ifoundation, and the ruling is effective for 2009, enter the date of the ruling pb Check box to indicate whether the foundation is a private operating foundation described in section I I 4942())-(Q) or I I 4942())(Q)

2 a Enter the lesser of the adiusted net Tax year Prior 3 yearsincome from Part I or the minimum (HI 2009 (UI 2005 (0) 2007 (U) 2005 (0) TWUinvestment return from Part X for

each year listedb 85% of line 2a

c Qualifying distributions from Part Xll,

line 4 for each year listedd Amounts included in line 2c not

used directly for active conduct of

exempt activities

e Qualifying distributions made directly

for active conduct of exempt activities.Subtract line 2d from line 2c

3 Complete 3a, b, or c for thealternative test relied upon:

a "Assets" alternative test - enter:(1) Value of all assets

(2) Value of assets qualifyingunder section 4942())(3)(B)(i)

b "Endowment" alternative test - enter2/3 of minimum investment returnshown in Part X, line 6 for each yearlisted

c "Support" alternative test - enter:

(1) Total suppon other than grossinvestment income (interest,dividends, rents, payments onsecurities loans (section512(a)(5))i or royalties)

(2) Support from general publicand 5 or more exemptorganizations as provided insection 4942())(3)(B)(iii)

(3) Largest amount of support from

an exempt organization

(5) Gross investment incomePart XV Supplementary Information (Complete this part only if the foundation had $5,000 or more in assets

at any time during the year-see the instructions.)1 information Regarding Foundation Managers:

a List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation before the close of any taxyear (but only if they have contributed more than $5,000). (See section 507(d)(2).)

NONEb List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the ownership of a partnership or

other entity) of which the foundation has a 10% or greater interest.

NONE

2 information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:Check here P III if the foundation only makes contributions to preselected charitable organizations and does not accept unsolicited requests for funds. Ifthe foundation makes gifts, grants, etc. (see instructions) to individuals or organizations under other conditions, complete items 2a, b, c, and d.

a The name, address, and telephone number ofthe person to whom applications should be addressed:SEE ATTACHED GRANT APPLICATION

b The form in which applications should be submitted and information and materials they should include:SEE ATTACHED GRANT APPLICATION

c Any submission deadlines:

SEE ATTACHED GRANT APPLI CATI ONd Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other factors:

SEE ATTACHED GRANT APPLICATION

azaooi 02-oz-1b Form 990-PF (2009)1 0

10060812 758432 ABBOCLA 2009 . 04011 CLARA ABBOTT FOUNDATION ABBOCLA1

F&m9%PFhwQ CLARA ABBOTT FOUNDATION 36-6069632 PWSHI Part XV I Supplementary Infonnation (continued)3 Grants and Contributions Paid During the Year or Approved for Future Payment

Recipient If recipient ls an individual,show any relationship to Foundation Purpose of grant or Amountany foundation manager SIBIUS Of COFITFIDUIIOFI

Name and address (home or business) or substantial contributor recipient5 Paid dunng the year

FINANCIAL AID AND NONE EN/A GENERAL AssIsfrANcE 6 , 263 , 764 .EDUCATIONAL SEMINARS *

SCHOLARSHIP GRANTS * NONE N/A EDUCATIONAL Assrsnucs 3 , 038 , 993 .

* THIS CONFIDENTIALINFORMATION IS NOTINCLUDED IN OUR RETURN.

THIS INFORMATION ISAVAILABLE AT THETAXPAYER"S OFFICE.

Total P 3a 9,302,757.b Approved for future payment

NONE

rmi P sb 0 .020000 00-00-00 Form 990-PF (zoos)11


1 I "Form 990-PF (2009) CLARA ABBOTT FOUNDATION 3 6 - 6 0 6 9 6 3 2 Analysis of Income-Producing ActivitiesEnter gross amounts unless otherwise Indicated.

1 Program service revenue:a

I Unrelated business income I isxaiuaea by section 512,51:-I,or su I (B)55.21,. (d) Related or exempt(al (bl

Bucsfgggss Amount 2311 Amount function income

b

1

g Fees and contracts from government agencies2 Membership dues and assessments

3 Interest on savings and temporary cashInvestments

4 Dividends and Interest from securities

5 Net rental income or (loss) from real estate:

a Debt-financed property

b Not debt-financed property

6 Net rental income or (loss) from personal

DFODBITY

7 Other Investment Income

8 Gain or (loss) from sales of assets otherthan Inventory 19 Net Income or (loss) from special events

10 Gross profit or (loss) from sales of inventory11 Other revenue:

a

b

c

d

e

12 Subtotal. Add columns (b), (d), and (e)

13 Total. Add line 12, columns (b), (d), and (e)

(See worksheet in line 13 Instructions to verifv calculations.)

14 5,940,748.

18 12,451.18 435, 824,727.p

o. (29,a71,52a.b o.13 429,871,528.)

Part XVI-B Relationship of Activities to the Accomplishment of Exempt Purposes

Line No. Explain below how each activity for which income is reported In column (e) ot Part XVI-A contributed importantly to the accomplishment ofV the toundation"s exempt purposes (other than by providing funds for such purposes).

92382102-O2-10 Form 990-PF (2009)

1 210060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

I A onForm 990-PF 2009) CLARA ABBOTT FOUNDATION 3 6 - 6 O 6 9 6 3 2 Page 1aPart XVII I Infonnation Regarding Transfers To and Transactions and Relationships With Noncharitable

Exempt Organizations1 Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) of YGS N0

the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?

a Transfers from the reporting foundation to a noncharitable exempt organization ot(1) Cash 1a(1) X(2) Other assets 1a(2) Xb Other transactions:

(1) Sales of assets to a noncharitable exempt organization 1b(1)(2) Purchases of assets from a noncharitable exempt organization 1b(2)(3) Rental of facilities, equipment, or other assets 1h(3)(4) Reimbursement arrangements 1b(4)(5) Loans or loan guarantees 1b(5)(6) Performance of services or membership or fundraising solicitations 1b(6)

c Sharing of facilities, equipment, mailing lists, other assets, or paid employees

d If the answer to any of the above is "Yes," complete the following schedule. Column (b) should always show the fair market value of the goods, other assets,

or services given by the reporting foundation. lf the foundation received less than fair market value in any transaction or sharing arrangement, show incolumn (rl) the value of the goods, other assets, or services received.

(8) Line no (D) AITIOUH1 IFIVOIVSG (C) Name Of fl0l"lCh8llt8bl6 BXCITIDT 0fQ8l1IZafl0l"l (U) Description of transfers, transactions, and sharing arrangements

N/A

*NNNNNNN

2a ls the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described

in section 501(c) ofthe Code (other than section 501(c)(3)) or in section 5279 lj Yes IZ-I Ngb lf "Yes," complete the following schedule.

(a) Name of organization I (li) Type of organization (c) Description of relationshipN/A IUnder penalties ol perjury, I declare that I have examined this retum, including accompanying schedules and statements, and tothe best of my knowledge and belief, it is true, correct,and complete Declaration of preparer (other than tax r fiduciary) is based on all information of which preparer has any knowledge

gQA 1645- IO Conhpjtcx /7?6a$an:r

efe

ir ,R Signature of officer or trustee Date F TitlePrepareris Date Chgck if Preparefs identifying number

S"gn H

er*sU Y

- - signature , DAVID LOWENTHAL 108/12/10 em layed v IT

a"dpare 0

E*

- m"sname(nryours BLACKMAN KALLICK, LLP EIN P

PPreUs

"Sell-employed). ,I 0 S . RIVERSIDE PLAZA , 9TH FLOOR"ms-*"" Z""*"" CHICAGO , ILLINOIS 6 0 6 0 6 Phone no. (3 1 2) 2 0 7 - 1 0 4 0Form 990-PF (2009)

923822D2-02-10

1 310060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

Schedule B Schedule of Contributors(Form 990, 990-Ez,

or 990-PF) P Amen io Form 990, 990-Ez, or 990-PF.Department of the TreasuryInternal Revenue Service

Name of the organization Employer identification number

OMB No 1545-0047

CLARA ABBOTT FOUNDATION 36-6069632Organization type (check one):

Filers of: Section:Form 990 or 990-EZ lj 501(c)( ) (enter number) organization

E 4947(a)(1) nonexempt chantable trust not treated as a pnvate foundation

2 527 political organization

Form 990-PF IE 501(c)(3) exempt private foundation

E 4947(a)(1) nonexempt charitable trust treated as a private foundation

II 501(c)(3) taxable private foundation

Check rf your organization is covered by the General Rule or a Special Rule.Note. Only a section 501 (c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

IE For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or property) from any onecontributor. Complete Parts I and ll.

Special Rules

E For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33 1/3% support test of the regulations under sections509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the greater of (1) $5,000 or (2) 2%of the amount on (D Form 990, Part VIII, line 1h or (iD Form 990-EZ, line 1. Complete Parts I and ll.

2 For a section 501(c)(7), (8), or (10) organization iling Form 990 or 990-EZ that received from any one contributor, during the year,aggregate contnbutions of more than $1,000 for use EXC/USIVG/Y for religious, chantable, scientiic, literary, or educational purposes, orthe prevention of cruelty to children or animals. Complete Parts I, ll, and III

II For a section 501(c)(7), (8), or (10) organization filing Fom1 990 or 990-EZ that received from any one contributor, during the year,contributions for use SXC/US/V6/.V for religious, charitable, etc , purposes, but these contributions did not aggregate to more than $1,000.If this box is checked, enter here the total contributrons that were received dunng the year for an SXC/USW6/.V religious, chantable, etc.,purpose. Do not complete any of the parts unless the General Rule applies to this organization because rt received nonexclusivelyreligious, charitable, etc., contributions of $5,000 or more during the year. P $

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990, 990-EZ, or 990-PF),but it must answer "No" on Part IV, line 2 of its Form 990, or check the box on line H of its Form 990-EZ, or on line 2 of its Form 990-PF, to certrfythat it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF).

LHA For Privacy Act and Paperwork Reduction Act Notice, see the Instructions Schedule B (Form 990, 990-EZ, or 990-PF) (2009)for Form 990, 990-EZ, or 990-PF.

923451 O2-01-10


I 4 *I Schedule B (Form 990, 990-EZ, or 990-PF) (2009) Page 1 of 1 of Part I

. Name ol organization Employer identification numberCLARA ABBOTT FOUNDATION 36-6069632Part I Contributors (see instructions)(2) (blNo. Name, address, and ZIP + 4

lc)Aggregate contributions

(dlType of contribution

1 MARIE E. WILKINSON

1415 N. DEARBORN, UNIT 24B $ 49,902.CHICAGO, IL 60610la) (bl

No. Name, address, and ZIP + 4(C)

Aggregate contributions

Person EPayroll IIINoncash III

(Complete Part Il if thereis a noncash contribution.)


2 SUZANNE PAVLUS

1 2 1 1 SPRUCE COURT $ 15,000.LIBERTYVILLE , IL 60048(2) (bl

No. Name, address, and ZIP + 4lc)


Person IIIPayroll ljNoncash II

(Complete Part ll if thereis a noncash contribution.)


3 MR. GUY R. WIEBKING

55 W. DELAWARE PLACE, APT 413 $ 1,000.CHICAGO, IL 60610(al (bl

No. Name, address, and ZIP + 4lc)


Person lilPayroll IINoncash II

(Complete Part ll "rf thereis a noncash contribution)


(2) lb)No. Name, address, and ZIP + 4

$

(clAggregate contributions

Person ljPayroll I:Noncash II

(Complete Part ll if thereis a noncash contnbution.)

(Cl)

Type of contribution

(2) (b)No. Name, address, and ZIP + 4

$

(C)


Person ljPayroll Z1Noncash Z(

(Complete Part ll if thereis a noncash contnbution )

(d)Type of contribution

923452 oz-oi-io Schedule B (Form1 5

10060812 758432 ABBOCLA 2009 . 04011 CLARA ABBOTT FOUNDATIO

$

Person EPaymii ENoncash E

(Complete Part ll if thereis a noncash contribution.)

990, 990-EZ, or 990-PF) (2009)

N ABBOCLA1

I g I" seheau1eB(Form ooo, ooo-Ez, or ooo-PF)(2ooo) Page 1 of 1 ofpanuName of organization Employer identification numberCLAR.A ABBOTT FOUNDATION 36-6069632Part ll Noncash Pr0p8rIfy (see instructions)

Ia)No. Ib)fT0m Description of noncash property givenPart I

IQF MV (or estimate)(see instructions)

Id)Date received

1980 SHARES OF ABBOTT STOCK @$50.92/SHARE

I2)No.

fromPart I

Ib)Description of noncash property given

49, 902

I0)

FMV (or estimate)(see instructions)

01/07/09

Id)Date received

Ia)No.

fromPart I


IC)


Id)Date received

Ia)No.

fromPart I


IC)


Id)Date received

Ia)No.

fromPart I

Ib)Description ot noncash property given

IC)


Id)Date received

Ia)No.

fromPart I


Ic)FMV (or estimate)(see instructions)

Id)Date received

923453 02-D1-10 Schedule B (Form 990, 990-EZ, or 990-PF) (2009)16

10060812 758432 ABBOCLA 20-09.04011 CLARA ABBOTT FOUNDATION ABBOCLAI

CONTINUATION FOR 990-PF, PART IVCLARA ABBOTT FOUNDATION 36-6069632 PAGE 1 OF 1f I P371 IV I Capital Gains and Losses forTax on Investment Income

(a) Llst and descrlbe the klnd(s) of property sold, e.g., real estate, (bI,Ifff,V*f"agt$al1s*ged (cg Date acqurred (d) Date sold2-story bnck warehouse, or common stock, 200 shs. MLC Co. D , Donatmn m0-I day. YV-) (m0-. day. YL)m RUSSEL 2000 P ARIOUS ARIOUSbRUSSEL 1000 P ARIOUS ARIOUSC CAP PRES ARIOUS KARIOUSdEAFE EQUITY INDEX ARIOUS ARIOUSe LEHMAN ARIOUS BARIOUSfRUSSELL 1000 NL ARIOUS ARIOUS

*U*U*U*U*U*U

lj THE NORTHERN TRUST ARIOUS ARIOUShNORTHERN BOND INDEX FUND ARIOUS ARIOUSi

-I

033-nr

Ie) Gross Sales We (0 De(%Ie:lIl?II?:bI2I)owed (gIuio2)tq?ern(2Q (eIhglt?:II)omIrIEsIg)7,479,967. 10,883,366. 43,403,399.)66,078,000. 96,612,106. 430,534,106.)45,222. 49,902. 44,680.)19,155,000. 24,397,894. 45,242,894.)53,007,200. 49,825,213. 3,181,987.59,786,010. 59,812,012. 426,002.)145,274. 8,666. 136,608.67,759. 67,759.

O53-XL--:fha-..cbc:.oo"m

Complete only for assets showlng gam rn column (h) and owned by the foundatron on 12/31/69 (I) Losses (nom Col, (h))- In x I . ..,F.M.v....frm1/.9 ffg$gI"f5g,3gg-S l*g,l,5:ggff,fgff,0,1-,gll Ga S* i?5F.%liZL$?I.?.a1?0?-le*""" "I

43,403,399.)430,534,106.)

44,680.)45,242,894.)3,181,987.

426,002.)136,608.67,759.

ODE-XL-:r&-..cuQ.o:J*m

. If , I I1 I, I 72 Capital gam net Income or (net capltal loss) ( If 32215)? 3gtEPIf5f."IEf,an Emile 7 I 2 (3 5 1 8 2 4 I 7 2 7 , )3 Net short-term capital gam or (loss) as deflned ln sectlons 1222(5) and (6):

If gam, also enter ln Part I, Irne 8, column (c).If (loss), enter "-0-" rn Pan I, Irne 8 3 N/A92350104-24-oo


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Em lo ee InformationU p Y Employees 8-digit Unique Person Identifier (UPI) number

(See Human Resources if you don"t know your number)

Abbott Employee Family Name Employee Hirst Name Employee Country

Employee Birth Date (oo/MM/YY) Employee Hire Date (oo/iviivi/YY) Employee Termination Date (oo/Mivi/YY)

Employee Job 1"itle Employee Division Employee Work Location (city)

Employee Status Code: Q Active Q Retired oateomeuremenitoo/iiiiii/YY) Yearsofserviee

Q Employee on Extended Disability Q Deceased Q Contractflemporary Employee

Employee Marital Status: Q Single Q Married Q Legally Separated Q Divorced Q Widowed

Employee Spouses Last Name Employee Spouse*s Hirst Name Employee Spouse"s Job Title

What iS y0ur r8lati0l1Ship t0 the Student? (Please netetltat the student must be a dependent child (age 24 or younger), in one of the categones listed below)

O Natural SOD/ Daughter O Step-SON Daughter (Must live with or be primarily supported by the Abbott employee)

Q Legally Adoptive Son/Daughter Q Other (explain)

Does the Abbott employee provide any type of financial support to the student? Q Yes Q No

Does the other natural parent provide any type of financial support to the student (l.e. child support, etc.)? Q Yes Q No

Complete information below (employee is yourself).

Name Age Relationship to Abbott Employee

1 Employee:

2. Spouse:

3. Student:

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- Family Income InfonnationAll requests for financial information MUST be entered in the currency ofthe country where the Abbott employee is being paid. Do notenter amounts in U.S. currency unless your country*s local currency is U.S. dollars.

1. Enter currency type used to complete the questions below (i.e. Euros, Pesos, etc.) 12. Total Year 2007 or 2008 gross annual income of Abbott employee 23. lf you are an Abbott retiree, please list pension or other money used for support 34. Total Year 2007 or 2008 gross annual income of other natural parent 45. Total Year 2007 or 2008 gross annual income of stepparent married to Abbott employee 5

6. Total Year 2007 or 2008 gross annual income of stepparent married to other natural parent 6

7. Total Year 2007 or 2008 gross annual income of widow/widower of Abbott employee 7Gross income is total Income from all sources including, but not limited to, salary, bonus and incentive pay, prior to any deductions.

List other dependents living within the household of and primarily supported by the employee: (Do not include the names listed in previous section)


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Student InfonnationStudent-"Familyaiilame Student First Name Middle Name

Student Country Student Date of Biith (Do/MM/YY) Students Clara Abbott ID Number

Student Marital Status (check one): Q Single Q Married Q Divorced Q Widowed Q Legally Separated

What is the highest level of education your father received?

Q Some Secondary School Q Secondaiy School Diploma Q Some Post-Secondary School Q Post-Secondary Degree(four-year degree)

What is the highest level of education your mother received?

Q Some Secondary School Q Secondary School Diploma Q Some Post-Secondary School Q Post-Secondary Degree- - (fourayear-degree)*"-Q-"1. Are your natural parents married to each other? 1. Q Yes Q No2 Are you, the student, currently in your last year of secondary/high school education? 2. Q Yes Q No

3. Have you, the student, completed a secondary education program? 3. Q Yes Q Nou4. Have you, the student, graduated with your first post-secondary degree (4-year degree) from a university? 4. Q Yes Q No

. *-u.u:..- ff.-...ti ..f-,.* .-.-f. f: pt -in-." -Q. --4 ,t.ft-1.-:e...iZc-. fm.-.C-r-"s*-is 7.- A-"l":"$q-IE-n":bf,1?e.*ai.-1-.-.-f .*:,i1f-.1-a-::ir..-f-t"-.f.@*,.2.-.",..-.fs.:4a ,f.:&.f".-%,"iir.:soma-z.f5:.:gj.H-at-..f 1 1.-P.?:,ec1JAaf%.:-iiaixwg-5 twig. -.4 LA.

*lib School Informatton

, w *Full Name of School Student Plans to Attend Campus Location (city)(Thls must be the complete ofticial name ot the post secondary school)

Estimated Total Annual School Costs

Enter estimated total annual tuition

Tuition tee A fee that is to pay for the actual education toattend a school (courses/classes) This fee is typically muchhigher than the registration fee Some countries do providefree tuition to studenis

Enter estimated total registration fees

Registration fee A fee associated with the administrativecosts for the school to enroll a student This fee is typicallymuch lower than the tuition fee

Enter estimated total annual book fees

Enter estimated total annual laboratory fees

Enter estimated total annual supply fees

Enter estimated annual other fees

F88 (please descnbe)

Fee (please describe)

Subtotal (Please add lines 2 7b)

---All Other Fees A

Students Expected Date of Graduation with a Hirst Degree (oo/MM/YY) School Country

Enter amounts in the currency of the country where the Abbott employee/retiree is/was 5 me 4paid (NOT where the student is studying) Do not enter amounts in U.S. currency unless . F *"" 0i ii i /1) NSchool Costs 3,2*

Enter Currency Type used to complete the questions 1. a ,...XV,..E,Xbelown e Euros, Pesos etc)

our coun *s local currenc is US dollars * *

2.

3.

4.

5.

6.

7a

7b

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Qlease NoiieReceipts will berequired for theseitems in1h"e1uture.

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1 Enter estimated total annual coaching/tutoring fees

2 Enter estimated total annual room and board

3 Enter estimated total transportation

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1.

2

3.

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r t* 3* 2009 Clara Abbott Scholarslii Pro"r(amA lication for Em lohemmfllit ti th USMd*P Witui "Wh ff lwf"wbM" M *W* "3"" * I-V .- 3- es" si ef e . ":-pan ,.ue o ico:-"-.i-f-ififn, tt : cara-.ab ott.com - ..E *wife if P -f v Yi. gf r xg * **i9B-935552-tu* 1.* D y tizffi". f.T:i*.ii"Zh"..":*2."-."+"eLe?I:-.*.L T-3?:-tiif-Ili.Eil-f*eE2%?.L%"l$5.ii:e2J(:i%:L35&2C1ff1i*&-L2iff(n"i1&ii:1i"L*.r*$i* I A*

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ChecklistYour application will only be considered when you include the following documentation with your application.

-Y

Cl 1. Official documentation of costs from the school the student plans to attend for the upcoming school year excluding room and board(accommodation), transportation, tutoring and/or coaching fees. Please provide one of the following:

0 itemized costs on official school letterhead

0 Costs detailed in school brochure (paper or printed copy from school Web site)

0 Actual school bill

0 Receipts from prior school year (if student is attending the same school as prior year)

EI 2. Verification that student is enrolled in a post-secondary institution. Please provide one of the following:

- Most recent student grade report

0 Document substantiating proof of enrollment such as a letter from school or identification card

El 3. Copies of employee income information (including Abbott employment income, pension income, self-employment income, etc.)

Cl 4. Copies of income information for all others that provide financial support to the student. For those who cannot provide proof of income,please complete and sign a Certification of Undocumented income form, available from your Human Resources representative.

III 5. Receipts from prior scholarship year This applies only to students who have received a scholarship from The Foundation in a prior yearAn additional form is included with your application if you are required to provide receipts. (lf you already provided these receipts as partof the official documentation of costs from item #1, please disregard.)

M.

- X (Required)To the best of my knowledge, the information on this application is complete and correct. By signing this application, I grant permission to TheClara Abbott Foundation (The Foundation) to make all inquiries they deem necessary to verify the, accuracy of the statements made on thisapplication. By signing my name below, I am *granting The Clara Abbott Foundation permission to" contact the students school for any additional

information on -the student. I understand that my personal data will be received by The Foundation in the U S. and that the U.S. may not have lawsthat protect my privacy to the same extent as my country*s laws. However, The Foundation will take all reasonable steps to protect my privacy.

The Foundation will not tolerate fraud, deceit or concealment with regard to the information on this application. lfThe Foundation determines thatany such behaviors have occurred, it may deny any curr-ent or pending application, and may not provide future assistance. For Abbott employees

, any such behavior is considered a violation of the Abbott Code of Business Conduct (the Code), and will be subject to the consequences as set outhilheCode. * . N , Iinformation provided to The Foundation is kept confidential except as required by law. The Foundation may decline any request for assistance atits sole and entire discretion

I Student Signature (Employee may sign forstudent) Date Employee Signature (Required) Date

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FormulirApIikasi Program Beasiswa Clara Abbott 2009untuk Pegawai di luar Amerika and Puerto Rico

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3.5:.-:zzTHE CLARA ABBOTT FOUNDATION

Aplikasi CASP Internaslonal v 5/08

, 55 X"

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15 Januari, 2009

PEDOMAN PERSYARATANA ,, " ," Af?APeghayvarfPensrunvanf-gg ff -ff" tg%5LA,:xff1@ *,233 5 Pgjajara* ,f * * f M " r I * aaI ,. 5%? . . f Y. f , 1 (M I X .- .- 1 .1 -,ai 3 ,Q .li *mfiffif f*3/"ig,-fQ*"SE5l 5 "fn1 f iegaranak pegavyarmemenuhisyarxatii-1ams,bekenaW , , , . Q ,1 ,fig ,A a

. I untuk Abbott atau bensiunan Abbott Pensiunan Abbott? 1 - I X :P"eIajar hams mahagigwa Han ana1fg5ati.1sr5e"rta"gradalah pegawaitbgfjaromurSakurarigkurangnya 50 1,, tanggungan pagawaiataurpensiujan barstaftusjggtahtzrn gengan rigaga kferjasmicnjrnufnigf/i1h0ftahun. Betfas fb? , Y NjAbbott? x fl "ig " . J ij,-if, I "1

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INSTRUKSI PENGISLAN PERMOHONAN/APLIKASI

1. Lengkapi Langkah 1 sampai Langkah 4 dari formulir aplrkasi ini. Seluruh pertanyaan harus dijawab.

2. Sediakan dokumen yang dipersyaratkan sebagaimana dirincikan di Langkah 5 aplikasi ini.

3. Harus membubuhi tandatangan pada Langkah 6 aplikasi ini.

4. Kembalikan aplrkasi berikut dokumen yang mendukung ke perwakllan SDM selambatnya pada batas waktu aplikasi internalyang berafnliasi dengan kantor Anda agar memenuhi-syar:at,Aplikasi yang melewati batas waktu yang ditentukan tidakditerima.

Mohon catat Seluruh pemohon yang menerima beasiswa diharuskan agar menyediakan tanda terima pembayaran untuk seluruhbiaya sekolah sebelum mengajukan kembali permohonan beasiswa dl masa mendatang. Perwakilan SDM Anda akan memberitahuAnda kapan memasukkan tanda terrma pembayaran tersebut Tanda Terima tersebut harus sesuai dengan jumlah beasiswa. Jikagagal menyediakan tanda terima tersebut, maka Seluruh keluarga Abbott tidak memenuhi persyaratan menerima bantuan danbeasiswa Clara Abbott

Qrtanyaan atau komentar? Hubungi wakil SDM Anda atau kunjung situs Clara Abbott Foundation Di http://c/ara.abbott.com. J

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SILAKAN BACA INSTRUKSI PADA HALAMAN PERTAMA SEBELUM MELENGKAPI APLIKASI INI

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Seluruh informasi finansial HARUS dalam kurs uang di tempat pegawai dibayar. Jangan masukkan dalam dolar Amerikakecuali jika kurs uang di tempat Anda memang dalam kurs dolar Amerika.

1. Masukkan jenis kurs untuk melengkapi pertanyaan di bawah ini (mis.. Euros, Pesos, dll). 1.

2. Pendapatan kotor total Tahun 2007 atau 2008 pegawai Abbott 2.

3. Jika Anda pensiunan Abbott, sllakan masukkan pensiun atau uang lainnya untuk membiayai 3.

4. Pendapatan kotor total Tahun 2007 atau 2008 orang tua kandung lainnya 4.

5. Pendapatan kotor total Tahun 2007 atau 2008 orangtua tiri yang menikah dengan pegawai Abbott 5.

6 Pendapatan kotor total Tahun 2007 atau 2008 orangtua tiri menikahi orangtua kandung lainnya 6

7. Pendapatan kotor total Tahun 2007 atau 2008 jandalduda pegawai Abbott 7".

Pendapatan kotor dari seluruh sumber termasuk, namun tidak terbatas pada, gaji, bonus dan bayaran insentif, sebelumdipotong.

Daftafnan tanggungan Iainnyzrdifdalam rumah atau sepenuhnya dltanggung pegawai:(Jangan masukkan nama yang telah disebut pada bagian sebelumnya)

Nama Usia Hubungan dengan Pegawai Abbott

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Nama Keluarga Mahasiswa Nama Depan Mahasiswa Nama Tengah

Negara Mahasiswa Tanggal Lahir Mahasiswa (TGL/BLN/T HN)

Status Pemikahan Mahasiswa: (ceksazu)

Blm Menikah Menikah Cerai Janda Berpisah Resmi

Tingkat Tertinggi Pendldikan Ibu Anda?Beberapa tahun di SMU

Diploma SMU

Beberapa Tahun di Universitas

Titel Sarjana(program sarjana 4 tahun)

Tingkat Tertmggi Pendldikan ayah Anda??Beberapa tahun dl SMU

Diploma SMU

Beberapa Tahun di Universltas

Titel Saqana(program sarjana 4 tahun)

1. Apakah kedua orangtua kandung Anda memkah? 1. Ya Tidak

2 Apakah Anda pelajar, sekarang ini di tahunterakhirSMU? 2. Ya Tidak

3. Apakah Anda telah menyelesaikan program SMU Anda 3. Ya Tidak

4. Apakah Anda pelajar yang telah menyelesaikan program Sarjana 4 tahun dari sebuah universitas? 4. Ya TidakK /

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Nama Lengkap Sekolah yang Akan Dimasuki Lokasi Kampus (Kota)/Harus Nama Lengkap Resm/ Sekolah Akadem/ alau Un/vers/Qs/)

-%ir

Tanggal yang diharapkan untuk Wisuda Negara Sekolahdengan Gelar Sarjana (TGUBLN/YY)

Jumsan

JUMLAH BIAYA SEKOLAH TOTAL TAHUNAN YANG DIPERKIRAKAN

Masukkan jumlah dalam kurs uang di tempat pegawai/pensiunan/dibayar (BUKAN di mana mahasiswa berkuliah).Jangan masukkan dalam dolar Amerika kecuali jika kurs uang di tempat Anda memang dalam kurs dolar Amerika.

Biaya Sekolah1. Masukkan Jenis Kurs melengkapi pertanyaan di bawah ini 1.

(mis. Euros, Pesos, dll)

2 Masukkan uang seicolahtotal-setahun: 2.Uang Sekolah: Biaya untuk membayarpendidikan untuk mengikutl kuiiah (mata kuiiah/kelas-kelas).Biaya ini biasanya Iebih tinggi dari biaya pendaftaran.Beberapa Negara memberikan kuiiah gratis.

3. Masukkan biaya total pendaftaran. 3Biaya Pendaftaran: Biaya sehubungan denganbiaya administrasi untuk masuk kuiiahBiaya ini biasanya Iebih rendah dari biaya kuiiah. Siiakan Catat:

Harus Ada Bukti pembayaran di- kemudian hari

4. Masukkan biaya total buku untuk setahun: 4. .5. Masukkan biaya total Iaboratorium untuk setahun" 5.

6. Masukkan biaya total kebutuhan kuiiah untuk setahun: 6.

7. Masukkan biaya total Iainnya untuk setahun:Biaya (ielaskan) 73.Biaya (1eIaskan)" -l-,il 7b -A-,-,-?Subtotal (T ambahkan baris 2-7b): -"

Biaya Iainnya

1. Masukkan biaya perkiraan total les/peiajaran tambahan setahun: 1

2 Masukkan biaya perkiraan total tempat tmggal/kamar. 2.

K5 Masukkan biaya perkiraan total transportasl. 3. J

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f- fi si(-Zvi if- ra *p P: --"-v.:.i-.-f:- 9 JF?, 5,. Aplikasi Anda akan dipertimbangkan jika dokumentasi berikut disertakan:

Dokumentasi resmi dan sekolah yang lngin dimasukl pelajar untuk tahun berikut tidak termasuk kamar atau asrama

(akomodasn), transportasi, blaya les tambahan dan/atau bimbingan, Slalakan sediakan satu document dari hal benkut ini:- Daftar Blaya di atas lembaran sekolah dengan cap resmi- Biaya rinci dalam bentuk brochure sekolah (lembaran kertas atau diprint dari situs sekolah)- Tanda pembayaran dan Sekolah yang sesungguhnya- Tanda terima dari sekolah tahun sebelumnya (jika mahasiswa bersekolah di tempat yang sama tahunsebelumnya) ,

Verifikasi bahwa mahaslswa berkuliah dl Akademi. Silakan sediakan satu dokumen dari hal berikut ini:

- Angka Rapot pelajar yang terbaru- Dokumen buktj bahwa mahaslswa memang sedang berkuliah di sekolah tersebut, blsa dalam bentuk surat dan

sekolah atau kartu identiflkasi

Salinan informasi pendapatan pegawai (tennasuk ga,ii-pegawai Abbott, pensiun, pemasukan swa-karya, dll )

Sahnan informasi pemasukan lainnya yang masuh menanggung blaya mahasiswa/pelajar tersebut. Bagi siapa yang tidak

dapat menyediakan bukti pemasukkan, silakan bubuhi tanda tangan Anda pada formulir Serliflkasl Pemasukan tidakTerdokumentasi, dlsediakan oleh penrvakllan SDM Anda

Tanda terima dari beasiswa yang sebelumnya Hal lni berlaku hanya bagi mahasiswa yang telah menerima beasiswa dari

Yayasan pada tahun sebelumnya. Formulir tambahan dimasukkan berikut apllkasi Anda jika Anda dlharuskanmenyediakan tanda terima. (Jika Anda telah menyedlakan tanda terima ini sebagai bagian dari dokumentasi resmibiaya-biaya dl atas, mohon lewatkan )

"aY7*""%*-: 7"?-" V- @3553# 1"Sejauhhsepengetahuan slayahinformasi dalam aplikasi ini adalah lengkap dan lbenar. Dengan membubuhi tanda tangan di

bawah lm, sayalmembenlkan :gm kepada Yayasan Clara Abbott (The Eounldlatlon) untuk mengagukan pertanyaan yang I .dnperlukan dem: mgamventikaslkan kebenaran pemyataan dl dalam aphkasn lm. Dengan, mem u uhl nlama saya dl bawah ml,saya mernbenlgan lzm kepada Ya%asan Qlara Abblottluntulk menghubungl gekolah em: memp-erolehllnformnasl tambahan,mengenal pelayar. Saya mqngem ahwa lnformasl pnbadl yang akan dl enma oleh Yayasan d1.Amenka Senkat dan AmenkaSerligat mungkln t1dak memlh I hukqm penrndungan pnvasl saya sepefh hqkum yang berlaku dl neagara saya. Namundemlk1an,Yayasan akan mengambll Iangkah bljak deml melmdungl pnvasl saya.

Yalyasan tidalg alganlmentoleransi penipuan, kecurangan, atau sikap menutupi,/merahasiakan. sehubungan dengan informasi dida am aphkasl gnl. .Iuka Yayasan menemukan adanya tlndakan tersebut, hal, ml akan mengaklbatkanpenolakan atau D

penundaan apllkasl, dan Udak akan menyedlakan bantuan dl kemqdlan han. Bagl pegtawal.Abbott, tlndakan tarsebut dlang?pEebagarll pelanggaran terhadap Kode Ehk Perusahaan, dan akan dlkenakan san sl se agar yang termaktub dl dalam Kode takerusa aan.

lnformasi yang disediakan Yayasan akan bersifat konfldensial kecuali jika dltentukan oleh hukum. Yayasan akan menolakpermlntaan bantuan sesuar dengan kebljaksanaan dan peraturan yang berlaku.

Tanda Tangan Pelajar (Pegawai dapat me wak///" tanda tangan pe/ajar) Tanggal

Tanda Tangan Pegawai (Wa//b) Tanggal

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y y dlichodcem gpolfegncjektl-Abtiotti. Ddohodce spolegddsi 3 Y byt zavfsly zefopatfenlm na zariieitflanci mg:-bot*G Abbott rrrusldobabnoytdyleku,alebpoi 50 rokga bracovat X * *dliohodci Spolefzriostl Abbott lf :Ft ff " *ig *X 2U/$bbbU*ll@l51@ll52l0ll@i&BYV3ll"ZHm@SlHHHCi?kTefl M0* J 5 "tb -Neylastnlitztl se irnohouprolgramujgiloastnit, pokud ulf podminky neSplhg11?"Se gemohou program .S-Upendllpro* 3 A iijivestejneqomacnosti nebojsquozavislar ja.. sye at rf . j* I fx *ff* I N., latex* .zzaopatrenlrn nazamestnamgl nebgducl1odclA.,Sf,. M** of Smluvmzamestnanqse nemohou programyguoastnlt: -3 ff .$53 jspolecnostl.Abbott..1, ,?..$&N.,vg -W, , ,* o Zamestnanec musi bytu Abbott zamestnan hejrhene i I o l (Student musi mit maturitu na sltredni Skole a chtlt sieff jeden rok kydatu podanifpF1hla5ek,f6i,musi uplynout doba I 1 1 zaelenitdo pomaturltniho studia na unlverzlte, "25 1* * -MF * T wk" tt- "f : CN.. fmt. -,.1 :.. K1,/alegppggednoho rolgu od akvlzlge dan(e,1ednJotkyH 3:5.. f .l V39 5 obchodnrg-1l5agemrg.nebo.1rrlyevysslodbomeskole.

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2. Pfedloite viechny dokumenty uvedene v Kroku 5 teto pHhla5ky

3. Pihlaeka musi obsahovat viechny podpisy uvedene v Kroku 6 teto pflhlaeky.

4. Tuto pihlaiku se veemi poiadovanymi dokumenty odevzdejte pracovnlku oddeleni lidskych zdrojd do koneoneho data podanlpdhlaiek stanoveneho prlsluenou atllacl. Na pfihlaiky podane po tomto datu nebude bran zfetel.

Upozorneni: Viichni iadatele, ktefi obdrii stipendium musi predloiit Uoty za viechny vydaje spojene se studiem pied podanimiadosti o dalii stipendium Pracovnik oddelenl lldskych zdrojfl ve va5l pobooce vam sdeli, kdy se maji Unity pfedloiit. Ur":ty musiodpovldat vyei stipendia. Pokud nebudou Unity predloieny, nebudou se mocl zamestnanci spoleonosti uchazet o dalii stipendia apomoc ze strany Nadace Clary Abbott.

Mate nejake dotazy nebo pfrpominky? Kontaktujte zastupce oddeleni lidskych zdrojll nebo navitlvte webovou stranku nadace ClaryAbbott (The Clara Abbott Foundation) na adrese http."//c/ara.abbo1t.com.

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Identifikafzni 8-mistna Ezislo zamastnance(pokud &islo neznate, obratte se na odd Ildskg"/ch zdroju)

Pfijmeni zamastnance Abbott Kfestni jmono zamastnance Zema , v nii zamastnanec pracuje

Datum narozeni zamastnance (D/M/R) Datum nastupu zamastnance (D/M/R) Datum ukonizeni zamastnani (D/M/R)

Funkce zamiastnance Divize, kde zamastnanec pracuje Mtsto pracoviita zamiastnance (masto)

Z3m@SU"t3I1eCkY Stavi Aktivni V dfICh0dU Datum odchodu do duohodu (D/Ml/R) - Roky zamistnani

Zamastnanec v dlouhodoba Zemfel Smluvni/dorfzasny zameistnanec

pracovni neschopnosti

Rodinny Stav zamastnancez svobodny ienaty/vdana odlouben rozvedeny/a vdovec/vdova

Pfijmeni manielky/a zamcfzstnance/kynfe Kfestni jmano manielky/a Funkce v zamastnani

Jaky je V25 p0m6r k Zamistnanci Abbott? Upozariu/eme, ie Zadatel musl byt zavrsly na zamastnanci (nesmi byt staril nei 24 let )a spadat do nakterd z niie,uvedenych kategoni

Vlastni Syn/dcera NeVlaStni Syn/dCera(Musi iit ve spoleinb domacnosh nebo zavrset vyilvou na zamostnanci Abbott)

Pravoplatna adoptovany/a syn/doera Jmy (vysvatlete)

Poskytuje zamastnanec Abbott studentovi najaky typ ftnanizni podpory? Ano Ne

Poskytuje druhy vlastni rodii: studentovi najaky typ fmanrini podpory (tj. ahmenty atd.)? Ano Ne

UpIn6 udaje (vy jste zamistnancem Abbott)

Jmano Vak Pomar k zamastnanci Abbott1 Zamastnanec/kyna.

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zevislez

Viechny poiadovane Udaje o finanfznich pomerech MUSi byt uvedeny v mene zeme, kde je zamestnanci Abbottu vyplaicenamzda. Neuv:-idejte Eaistky v dolarech, pokud neni oflciailni menou vaii zeme americky dolar.

1. Uvedte menu, v nii budete vyplhovat nzlzsledujici kolonky (tj. Euro, Pesos, atd )

2. Celkovy hruby piiiem zamestnance Abbottu za rok 2007 nebo 2008

3. Pokud jste dfxchodce Abbottu, uvedte vy/Si dnichodu nebo june peneini poiltky

4. Celkovy hruby pfijem druheho vlastniho rodi6e za rok 2007 nebo 2008

5, Celkovy hruby rocfzni pfijem nevlastniho rodi6e oddaneho se zamestnancem Abbottu za rok 2007

6. Celkovy hruby piijem nevlastniho rodlie oddaneho s druhym vlastnim rodlbem za rok 2007

7. Celkovv hmby pfijem vdovy/vdovce po zamestnanci Abbottu za rok 2007 nebo 2008

Hruby pfijem je celkovy piijem ze viech zdrojfx, vfzetne - aviak nikoli jenom - platu, premii a motivafznich Eestek pied v5emi

Uvedte viechny dalii osoby Zljici ve spolebne domecnostl se zamestnancem Abbotu nebo ktere jsou na ieho inanbni podpofe

(Neuvddejte jmena osob, ktere jste uvedli v piedchizejici iisti)

Jmeno Vek Pomer k zamestnanci Abbottuye# we /

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Pfijmeni studenta Kfestni jmcfrno studenta Prostfedni jm6no

Zemci, v nii student iije Datum narozeni studenta (D/M/R)

Rodinny stav studenta: (zaskrmere pfis/uine)

Svobodny/6 Zenaty/vdani Rozvedeny/at Ovdovcily/6 Pr:51vopIatn& odloufzen/a

Jaky je nejvyiii stupefm dosaienfeho vzd&l2ni vaii matky?Stiedoikolskzi. Absolventka pomaturitniho studiaMaturita na stfedni Ekole Absolventka pomaturitniho 6tyHet6ho vysokoikolskeho studia

Jaky je nejvyiii stupefm dosaieneiho vzdcilizni vaieho otoe?Stfedoikolskei Absolvent pomaturitniho studiaMaturita na stiedni Ekole Absolvent pomatun"tniho E:tyFIet&ho vysokoikolskiaho studia

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Vase piihliska bude pfijata pouze tehdy, jestliie k ni piiloiite niie uvedenou dokumentaci.

Oicielni dokumentaci nekladu ze skoly, kterou student hodle navstevovat piisti skolni rok s vyjimkou poplatku za

ubytoveni a stravu, dopravu a poplatku za vyuku a konzuitace. Prosim, pfiloite jeden z nesledujicich dokumentu:- Rozepsane neklady podle poloiek na oticlelnim hlavifzkovem papife skoly- Podrobne rozepsane neklady uvedene v broiuie skoly (vytistene kopie z intemetovych strzinek skoly)- Skuteciny ufzet vystaveny skolou- Urfztenky za vydaje z piedchizejiciho skoiniho roku (pokud student pokraciuje na stejne skole i dalsi rok)

Ovefeni, ie student je zapsatn v instituci vyssiho vzdelaiveni. Prosim, pfedloite jeden dokument Z niie uvedenych"

- Zpravu z posiedne studovaneho roeniku .- Dokument potvrzujici, Ze student byl zapsan do skoly (dopis od skoly, index, iegitimace skoly)

Kopie potvlzeni o piijmu zamestnance (vcfzetne pfijmu zamestnance Abbottu, duchodu, piijmu OSVC, atd)

Kopie potvrzeni o pfijmu ostatnich osob, ktere se podileji na zaopatieni studenta Ti, ktefi nemohou piedloiit dukaz o vysi

pfijmu, vyplni a podepisi Certifikzllt nedoloiene vyse piijmu (Certification of Undocumented Income).Tento formuleivyde pracovnik oddeleni lidskych zdroju.

Uetenky za vydaje za pfedchozi rok, kdy student pobiral stipendium Toto plati pouze pro studenty, ktefi minuly skolni rok

pobiraii stipendium od Nadace. Spolu s formuletiem iedosti dostanou daisi formuliafti studenti, od kterych se vyiadujepiedloieni ufztenek. (Pokud student iii pfedloiil tyto uetenky v reimci oticiatini dokumentace vydaju, tento bod pro nejneplati.)

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Pogtleumeho nejlefsiholvedomi Lsou vsechny informaoe uyedene v teto pihlasce uplne a spravne. Podepsanifg teto pflhlaskyudelujlvpovoleunu* adacl Clary/A bott (Nactace) pot-dadat vsechny dotazy, ktere bude povazovat za nutne k oyerenl presnostl

prohlaseni uclnenych y teto %nhIas.ce.,Sv?/m podplsem uvedenglm mze udelujl Nadacu Clary Abbott povplem, abaf kontaktovalaskolu studenta, bude-Il gotfe Qvat jalgeko I dalsi mform-ace o s gientovt Beru na yedpml, ze maosobnl, data bu ou ,postoupena Nadacl ve pojenyph statech a ie ve Spojenycb statech gemusl platlt zakony, kteqe chranl osobol gata v takovemrozsahu yako zakony v me zemt., avsak Nadace podnlkne veskere mozne kroky, aby ma osobm data byla chranena.

Nadace nebude tolerovat pod)/od, klamaqi 6i skryvanilfvaktu v souyislosti -sjnformacemi uvedenYmi v teto pihlasce. Pokudnadage nabuge dojmu, :Ze dosto k pekteremu jevug vyse uvedenych, muze ovdmltnout kterouko I godanou nebo dosud,nevyrlzen-ou zadostva .nebude nadale poskytovat zadoou Idalsg ppmoc. 1) zamestnancu spolecnos Abbott se takove vyseuvedene jevy povazuji za poruseni Kpdexu obohodmho jednanl spolecnostl Abbott (Abbott Code of Business Conduct)(Kodex) a vyvolali nasledky, uvedene v Kodexu.

Infqrmace poskytnute Nadaci jsou ohraneqy jako duyerne s vyjjmkou, tech, ktere jsou uvedeny v pfislusnem zakonu. Nadacemuze odmntnou jakoukoh pomoc vyhradne podle sveho vlastnlho uvazem,

Podpis studenta (Zamestnanec se muie podepsat m/"sto studenta) Datum

Podpis zamestnance (Povinny) Datum

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Demande d*inscription au programme de bourses d*6tudes2009 de la Fondation Clara Abbott pour les employas a

Vextarieur des Etats-Unis et de Porto Rico


Demande d lnscrlptron Internationale au programme de bourses d etudes de la Fondation Clara Abbott v 5/08

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DATE LIMITE D*lNSCRlPTlON I

CRITERES UADMISSIBILITE

?V%mpl,oyes ei retrtdifesaf" 5 " "ie 1* tl :PtnfiiVr3que*ison pu seste/iifants soientaiimissiblesfzf A

" - Uenfploye doitietre/unc salaije" ougtun retraite A350Les retraites d Abbott doiveijt etre ages dau moins50 aijs "etavoiiffitraivaillle ati3ifioins*10 ansirppur la,

Societe. Leswagxncielnshempldyes qui nevtfoijlfespoiggpasaicette* dejnition* nevlsoizt pasladmissiblesliLes employesllsyouls coiitiatfne sont pasiadmissibleUn employe doit compter au moinisune annietawde A3 1service a la date limite dinscription ou une anneeai*parlirgeipla date diaoquisitiori par2AblQQtt.t f " , I , H M x V ,I A 1 Y A

sq Llemployejdoitftraivailler au moins&2(),$tieures par" 1 ecolercommerclale ouispecjalis/ee: J V I A* Xe*it f*Z*w?*f 3 J? *fee *I .35 A5# - D."3,y * 2,. .1.s,tf*vfs...f A. " :. fee. Ag I *ft tvsemainegg , ,- Un etudiant ne doit pas avoir plus de 24 ans a laidateisrdiecheenceide Piesenteififigdeg demandes. Y , .f. s Q, , fs 2. : riwm

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ti principale sourcefde soutien financier, , 1 ti5 Un etudiantdoit-etre di lome d*une ecole secondaire- ..t,.a:f - .J .,, X. 3,4*

et doit prevoir s inscnre a un programmed etudesta postsecondairestdispense par une universite, ou une

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lNSTRUCTlONS RELATIVES A LA DEMANDE

1. Veuillez remplir au complet les etapes 1 a 4 du present formulaire, en repondant a toutes les questions.

2. Foumissez les documents requis indiques a l"etape 5 du present formulaire.

3. Obtenez les signatures requises a Vetape 6 du present formulaire

- 4. Pour etre considere comme admissible, envoyez le present formulaire et les documents justificatifs a votreJepfe.semam1esIRessources humaines avant la date limite d"inscription en vigueur dans la Hliale. Les demandes regues en retard serontrefusees.

Nota: Tous les candidats qui ont recu une bourse doivent fournir des recus de tous leurs frais de scolarite avant de faireune autre demande de bourse dans llavenir. Votre representant des Ressources humaines vous avisera du moment oii vousdevrez fournir vos recus. Ces derniers doivent correspondre au montant de la bourse recue. Les candidats qui ne presentent pas derecus de frais de scolante empecheront tous les membres de leur famille dletre admissibles a toute bourse ou aide tinanciere futurede la Fondation Clara Abbott.

Si vous avez des questions ou des commentaires, veuillez communiquer avec votre representant des Ressources humaines ou

Qnsultez le site Web de la Fondation Clara Abbott, a Vadresse http://clara.abbott.com. J

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IMPORTANTI

VEUILLEZ LIRE LES INSTRUCTIONS A LA PREMIERE PAGE AVANT DE REMPLIR CETTE DEMANDE

fe-iizsw-Y 1 Ysifii i-"sisVEILLEZ ECRIRE EN T D"IPRIMERIE OU ENTRER LES RENSEIGNEMENTS ELECTRONIQUEMENT

. x-.g .3 i -.i.Ii,I*-,,- - QL. L1 - 3,.a:.f. ,,EI"6Iu-..,.:*,*,,,,-,ff2".F-,$7-.-v,:, , . , , I--v A 1,15 143,57, A ,,fgw-1?-,iw-U14. 13,--5n.1,.f.A-/. ,M1. XNumero didentitication personneiie (UPI) a 8 chiffres de Vemploye(Si vous ne connaissez pas votre numeio, adressez-vous aux Ressources humaines )

Nom de famille de Iempioye d"Abbott Prenom de l"employe Pays de Yemploye

Date de naissanoe de Iemploye (JJIMM/AA) Date d"embauche de Vemploye (JJ/MM/AA) Date de cessation d"empIoi de Vemploye (JJ/MM/AA)

Poste de Vemploye

* Statut de Iemploye

Etat matrimonial de Yempioye :

Division Lieu de travaii (ville)

Actif Retraite Date de Ia retraite (JJIMM/AA) .,- Nombre d"annees de service

Employe qui reooit des prestations d"invaIidite de Iongue duree Decede Contractuel /Temporaire

Ceiibataire Marie Separe legalement Divorce Veuf

Nom du conjoint de Vempioye

Enfant naturel

Enfant adopte Iegalement

Lien entre Vetudiant et I"empIoye d"Abbot"t

Prenom du oonjoint de Vemploye Poste du conioint de Vemploye

Veu///ez nater que /e cand/dat doit etre un enfant 5 /a dia/ge de /"emp/aye age* de 24 ans ou mo/ns et appanen/ra" /*une des cateigones a-dwsous

Enfant par TEITIBFIBQS (dart vrvre avec Vemployi d "AbbotLau.de"pen.fiLe.de.Zw.ca:n.*ne,pnncipalesource de soutien financier)

Autre (expliquez)

Est-ce que Vemploye d"Abbott apporte un soutien financier a Vetudiant? Oui Non

Est-oe que I"autre parent naturel appoite un soutien tinancier a Vetudiant (p. ex , pension alimentaire)? Oui Non

Remplissez Ia section ci-dessous (Vemploye est vous-meme).

om Age Lien avec I"empIoye d*Abbot1so --1-.Employer --- ""-#*-- -**E* - -vf*-s--i---------- v- ----

2. Conioint:

3. Etudiam:X /1

5 -. . Rgxvstx-,e at 91.5,* $4555, , -.,.-.y..gv1,li2&5,5.-.f. ei iq. W y...z, , 44,. V ., -1,115 * ....1 - R any 1* T 3,1-.mtv-1 *#41,-. ,. .1 -,-,..5V.K.,.-I ..-.gxngn-75,.-.. . . .. - .. -. . - . - - . . .-, , A ,- . h : 5%.. * .mf 5 1,. s-.2 , g 1, . -1-, .- at--rf."-Q.. , rr I 1 -1...* 1 -*P W -yg,-5%*r rr * .- fer -. * QI IMPORTANTI

VEUILLEZ LIRE LES INSTRUCTIONS A LA PREMIERE PAGE AVANT DE REMPLIR CEITE DEMANDE

- * * rv . 52: " 1 " . - . ...1 M- -1,, .fe-.**- 335.. EII3 f2I.*5,Lr:r.u f-.rlrr-:T$L1,*-31552, 14"* Eff.. I1 0*"* *L "V" . *":"Jj*r*.j if fidii " -if" /il.-f3.S"5/,A I "S153:-iiiii"-.-1 2 "A-1? -ff"-:3""f.*7I *$51-*"f15"f f *ll* "7"if*5*:27f/i""?E$-5i"2l-53137111J *-*$7 -1.7" "&fH"fI72?"*Z*.1.5f"" ."fiifiig f 5

.Tous les montants demandes DOIVENT etre inscrits dans la devise du pays ou l"employe d"Abbott recoit son salaire. N"entrezles montants en dollars US que si la devise de votre pays est le dollar americain.

1. lndiquez la devise utilisee pour repondre aux questions ci-dessous (p. ex., euros, pesos, etc.). 1.

2. Revenu total en 2007 ou revenu brut annuel de 2008 de lemploye d"Abbott 2.

3. Si vous etes un retrarte d*Abbott, rente de retraite ou autre source de soutien financier 3..i4. Revenu total en 2007 ou revenu brut annuel de 2008 de l"autre parent naturel 4.

5. Revenu total en 2007 ou revenu brut annuel de 2008 du nouveau conjoint de l*employe d*Abbott 5.

6. Revenu total en 2007 ou revenu brut annuel de 2008 du nouveau conjoint de l"autre parent

6.naturel de Vemploye

7. Revenu total en 2007 ou revenu brut annuel de 2008 du veuf ou de laveuve de Femploye d"Abbott 7.

Le revenu brut est le revenu total provenant de toutes les sources, incluant, entre autres, le salaire, les primes et le salaire aurendement avant toute retenue salariale.

Enumerez toutes les autres personnes a charge qui vivent chez Vemploye et dont Vemploye est la principale source de soutienfinancier :

(N"inscrivez pas le nom des personnes enumerees dans la section precedente)

Nom Age Lien avec lemploye d"Abbott& /

. , 1I . , .. . W , ,, , .5 5,, 1 1: J..-.1., H." -" " ** "*f*I",J,..(:**2$"-lir*:$1,4.r.***i%f?I"1z*-fJI4gY5 - ff .- *ww m -ji .N-t 1.--fig .-vg-fg-5,--f-- -1"-- ,fm I- fa F 1% *is* ri @ " e" --*fs-we-as "@.U?11"f,"s,- He :fi."rf.uef:-warfare "-we o , V be-.ig 5 Q9 f " * 5% - .. , 1-ra-3,., .yi " I.. ,.-1 .. - fm- E-,..:i,. 4-.-. fr . .effe5.2.%

IMPORTANTI


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Nom de famille de Vetudiant Prenom Second prenom

Decede Date de naissance de Vetudiant (JJ/MM/AA)

Etat matrimonial de I"etudiant :

Celibataire Marie Divorce Veuf Separe Iegaiement

Quel est le niveau de scolante de votre mere?Secondaire IV ou moins Certiiicat detudes postsecondaires

Diplome d"etudes secondaires Diplome d*etudes postseoondaires (quatre ans)

Quel est Ie niveau de scolarite de votre pere?Seoondaire IV ou moins Certiicat d"etudes postsecondairesDiplome d"etudes secondaires Diplome d"etudes postsecondaires (quatre ans)

1. Vos parents naturels sont-ils maries Fun e Vautre? 1. Oui Non

2. En tant que Vetudiant vise par cette demande, en etes-vous a votre demiere annee d*etudes secondaires? 2 Oui Non

3. En tant que Vetudiant vise par cette demande, avez-vous tennine vos etudes secondaires? 3. Oui Non

4. En tant que Vetudiant vise par cette demande, avez-vous deja un diplome d"etudes universitaires (quatre ans) 4. Oui Non

I5

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IMPORTANTIVEUILLEZ LIRE LES INSTRUCTIONS A LA PREMIERE PAGE AVANT DE REMPLIR CEITE DEMANDE

.1i..*es:2":.f:gF-,gidvffzqggzfxfizzsc $5. c-551-2??-.ff .: -".*f::1-r-.-,"a::zi-2".-" tt ggsarfsg 1:5:aa. pi -ef..-.mt we Q-fs, f.-.1 af.,,,7,-,:,- Wi-" .. -we fir? nf f, atNom complet de Vetablissement ou l*etudiant prevoit s"inscrire Emplacement du campus (ville)(Nom ohio/el aomp/ei de /*ebb//ssement postsewnda/re)

Date prevue d"obtention du dlplome de premier cycle (JJ/MM/AA) Pays de Vetablissement d"enseignement

Domaine d"etudes

FRAIS DE SCOLARITE ANNUELS TOTAUX ESTIMATIFS

Entrez les montants dans la devise du pays ou Vemploye ou le retraite d"Abbott est ou etait paye (et non celle dupays ou l*etudiant poursuit ses etudes). N*entrez les montants en dollars US que si la devise de votre pays est Ie dollararnericain.

Frais de scolarite1. lndiquez la devise utilisee pour repondre 1

aux questions ci-dessous (p. ex., euros, pesos, etc.)

2. Frais de soolarite annuelstotaur.-estimatifs : 2Frais de scolarite : Frais engages pour Feducationdans un etablissement (cours).Ces frais sont generalement beaucoup plus elevesque les frais d"inscription. Dans certains pays,Veducation peut etre gratuite.

3. Frais d"inscription annuels totaux estimatifs . 3.Frais d"inscription : Frais d"administration deVetablissement d"enseignement. Ces Irais sontgeneralement beaucoup moins eleves que lesfrais de scolarite. Nota :

" Des requs de ces frais4. Frais de livres annuels totaux estimatifs. 4. - seront exiges dans l*avenir.5. Frais de materiel de laboratoire annuels totaux estimatifs : 5

6. Frais de foumitures annuels totaux estimatifs . 6

7. Autres frais annuels totaux estimatifs 1FEIS (veulllez mdiquer le type) I 7a.

1 -- -Q -Flals (veuillez mdiquer le type) " li* 7b ii.Total partiel (additionnez les lignes 2 a 7b) :

Autres frais

1. Frais d"encadrement ou de tutorat annuels totaux estimatifs : 1.

2. Frais de chambre et pension annuels totaux estimatifs : 2.

3 Frais de transport annuels totaux estimatifs : 3. J

.

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Votre demande ne sera pas prise en compte si vous n"y joignez pas les documents suivants.

Document officiel des frais de scolarite emis par Vetablissement d*enseignement ou l"etudiant prevoit s"inscrire pour la

prochaine annee scolaire, a Vexclusion des frais de chambre et pension (hebergement), de transport, de tutorat oud"encadrement. Veuillez foumir l"un des documents suivants :

- Liste detaillee des cofits sur papier en-tete ofticiel de Vetablissement denseignement- Liste detaillee des couts dans la brochure de letablissement denseignement (copie papier ou imprimee du site Web

de Vetablissement denseignement).- Facture des frais de scolarite.

- Regus de l"annee scolaire precedente (si l*etudiant frequente la meme ecole que lannee precedente).

Contirmation que lletudiant est inscrit dans un etablissement postsecondaire. Veuillez foumir l*un des documentssuivants :

- Demier bulletin de notes de l"etudiant.

- Document attestant linscription, comme une lettre de l"eoole ou une carte d"idei:itite.

Copie de Vinformation sur le revenu de Vemploye (incluant le salaire, les rerites de retraite, le revenu d*un travailindependant, etc.)

Copie de Ilinformation sur Ie revenu de toute autre personne qui offre un soutien financier a I"etudiant. Si aucune

preuve de revenu n*est disponible, veuillezrenipiiretsignerieformulaire Attestation de revenu non documente,disponible aupres de votre representant des Ressources humaines.

Regus des frais de scolarite de l*annee precedente. Cette exigence ne s*applique qu*aux etudiants ayant recu unebourse d"etudes de la Fondation lors d"une annee anterieure. Un formulaire supplementaire est inclus avec votredemande si vous devez fournir des recus (Si vous avez deja fourni ces recus comme pieces justihcatives ofbciellesdes frais indiques ci-dessus, veuillez ne pas tenir compte de cette mention.)

- *H* is-at ar.-H. 15:11- -,zla-1-:fa 1: -1.-1.-Lp,.--/ ., *.f..,3.7,:-*.fjl:5l-5,.-If -3.5,,--jV*9,.:-:viea 1.44.5--,*ifiaai:i.asift@a:isE.5,eE1liiAfif2z:aif%fZ2:.,@

A ma connaissance, les renseignements fourriis dans cette demande d*inscription sont comgiets et exacts. En signant cettedemande d"inscrifotion, ie pennets ahia Fondation Ciara Abbott sta Fondationg de faire toute emande qu*eIie iuge necessairepour ventier I*aut entici e des renseignements fourms dans cet e demande *inscription En signant mon nom ci-delssous,

fautorise Ia Fondation Clara Abbott a prendre contact avec Vetablissement denseignementupour obtenir tout regseignementadditionnel sur I*etudia-nt. Je comprends que mes donneeslpersonnelies serpnt transmises a la Fondahon aux tats-Unis et

glutl se peut que les to-is de cegays ne protegent pas ma vie pnvee de ia meme manierenquellels Iois de mon pays.eanmoins, la Fondation pren ra toutes les mesures raisonnabies afin de proteger ma vie privee.

La Fondation ne tolerera aucune fraude, falsification ou dissimulation de renseignements dans cette demande dinscription. Sieite determine qu"ii y a eu fraude, faisihcatton ou dissirnuiation elle peut refuser toute demande d*inscription actuelle ou ensuspens et pourra refuser d*offnr tout soutien a I"avenir. Chez-tes empioyes d*Abbott, ce genre de comportement est tenu pourune infraction au code de conduite d"Abbott (le code) et entraine les repercussions etablies dans Ie code.

Les renseignements fournis a ta Fondation restent conidentiels, sauf dans les cas prevus par Ia toi. La Fondation peut refusertoute demande de soutien a sa seule et entiere discretion.

Signature de Vetudiant (Vempioye peut signer pour Vetudiant) Date

Signature de Vemploye (obiigatoire) Date

*rr

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filr Mitarbeiter auflerhalb der USA und Puerto Rico

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HINWEISE ZUR BEANTRAGUNG

1. Fiillen Sie die Abschnitte 1 bis 6 dieses Antragsformulars vollstiindig und in Druckbuchstaben (keine Schreibschrlft) aus.Beantworten Sie samtliche Fragen.

2. Fligen Sie die in Abschnitt 5 in diesem Antrag genannten erforderlichen Unterlagen bei.

3 Verseiteti-iS*ie*1dze*ser-x:Antr2g-in Abschnitt 6 mit den erforderlichen Unterschriften.

4. Senden Sie dlesen Antrag und die zugehorigen Unterlagen bis zum internen Anmeldeschiuss der Tochtergesellschaft an denzustandigen Mitarbeiter lhrer Personalabteilung vor Ort zuriick. Antrage, die nach diesem Datum eingehen, konnen Ieidernicht berucksichtigt werden.

Hinweis: Alle Bewerber, die ein Stipendium erhalten, miissen Belege iiber samtliche Studlengebiihren beibringen, bevor sie sichfir ein weiteres Stipendium bewerben. lhre Personalabteilung wird Sie informieren, wann Sie die Belege einreichen sollen. DieSumme der Belege muss mit dem Betrag des Stipendiums ubereinstlmmen. Sollten diese Belege nicht vorgelegt werden, wird diegesamte Familie des Abbott-Mitarbeiters von allen zukunftigen Stipendien und Leistungen der Clara Abbott Foundationausgeschlossen.

- 1.- - -Fragen.oder.Anmerkungen?.Wenden Sie-sichan einen Mitarbeiter lhrer Personalabteilung-vor Ort oder besuchen-Sie-die-Webseite - -

wr Clara Abbott Foundation unter http."//c/ara.abbofI.c0m. J

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8-stellige UPI-Nummer des Mitarbeiters(Wenden Sue slch an HR, wenn Sue Ihre Nummer mcht kennen)

Nachname des Abbott-Mitarbeiters Vomame des Mitarbeiters Wohnland des Mitarbeiters

Geburtsdatum des Mitarbeiters Emstellungsdatum des Mltarbeiters Datum der Beendlgung des Arbeitsverheltnisses(TI/MMIJJ) (TT/MM/JJ) (TT/MM/JJ)Berufsbezeichnung des Mltarbeiters Abteilung des Mitarbeiters Einsatzort des Mitarbeiters (Stadt)

Telefonnummer des Mitarbeiters (gesch.) Telefonnummer des Mltarbeiters (priv.)

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Familienstand des Mitarbeiters: Ledig Verheiratet Gesetzlich getrennt Geschieden Verwitwet

Nachname des Ehepartners des Mltarbelters Vomame des Ehepartners des Mitarbeiters Berufsbezeichnung des Ehepartnersdes Mltarbeiters

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Gesetzlich adoptierte/r Sohn/Tochter Sonstlge (bitte angeben)

Wlrd der Studlerende in irgendeiner Form vom Abbott-Mltarbelter fmanziell unterstutzt? Ja Neln

Wird der Studierende in irgendeiner Form vom anderen Ielbllchen Elternterl tinanziell unterstutzt (d. h. Unterhaltszahlungen etc )? Ja Neln

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Alle tinanziellen Angaben MUSSEN in der Wihrung des Landes erfolgen, in dem der Abbott-Mitarbeiter sein Gehalt bezieht.Geben Sie Betrege nur in US-Dollar an, wenn auch lhre 6rtliche Landeswihrung US-Dollar ist.

1. Geben Sie die Wehrung an, die zur Beantvvortung der unten aufgefiihrten Fragen verwendet wird (z. B. Euro, Pesos, etc.)

1.

2. Gesamtjahresbruttoeinkommen des Abbott-Mitarbeiters fiir das Jahr 2007 oder 2008

2.

3. Wenn Sie sich im Ruhestand befrnden, geben Sie bitte die entsprechende Rentenhohe oder sonstige Unterstiitzungsgelder an

3.

4. Gesamtjahresbruttoeinkommen des anderen Ieibiichen Eltemteils fiir das Jahr 2007 oder 2008

4.

5 Gesemtjahresbruttoeinkommen des mit dem Abbott-Mitarbeiter verheirateten Stiefelternteils fur das Jahr 2007 oder 2008

5

6. Gesamtjahresbruttoeinkommen des mit dem anderen leiblichen Elternteil verheirateten

Stiefelternleils fur das Jahr 2007 oder 2008 6T Gesamtjahresbruttoeinkommen des Witwers1der*Wrtwe des Abbott-Mitarbeiters fiir das Jahr 2007 oder2U08*

7.

Bruttoeinkommen bedeutet das Gesamteinkommen aus allen Bezugsquellen, einschlieBlich Gehalts-, Bonus- undLeistungszuzahlungen vor Abzug von Steuern oder sonstigen Abgaben.

Bitte geben Sie sonstige Unterhaltsberechtigte an, die im Haushalt des Mltarbeiters Ieben oder fur deren Unterhalt dieserhauptseichlich verantvvortlich ist" (Die im vorherigen Abschnitt angegebenen Personen mirssen nicht erneut aufgefuhrt werden.)

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Telefonnummer des Studierenden

Familienstand des Studierenden: (B/me Enrspredvendas an/rreuzen)

Biite geben Sie den h6chsten Schulabschiuss lhrer Mutter an.Mittierer Schulabschluss weiterfiihrende AusbiidungAbitur/Fachhochschuireife Hochschulabschiuss (vierjiahriger Studiengang)

-A Bitte geben Sie den h6chsten Schuiabschluss Ihres Vaters an.j Mittlerer Schulabschluss weiterfiihrende Ausbildung

Abitur/Fachhochschuireife Hochschuiabschluss (vierjahriger Studiengang)

1. Sind Ihre leiblichen Eltern miteinander verheiratet? 1. Ja

2 Beindet sich der Studierende zurzeit im letzten Jahr seiner Ausbildung in der weiterfiihrenden Schule? 2. Ja

3. Hat der Studierende die weiterfiihrende Schule abgeschlossen? 3. Ja

Nachname des Studierenden Vomame des Studierenden Zweiter Vomame

Ledig Verheiratet Geschieden Verwitwet Gesetzlich getrennt

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Nein

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Voraussichtiiches Ausbildungsende fiir ersten Landweiterfiihrenden Abschluss (Ti/MM/JJ)

Faohrichtung

VORAUSSICHTLICHE GESAMTKOSTEN PRO STUDIENJAHR

Bitte geben Sie den entsprechenden Betrag in der Wahrung des Landes an, in dem der Abbott-Mitarbeiter/-Pensionir seinEinkommen beziehtlbezog (NICHT des Landes, in dem der Bewerber studiert). Geben Sie Betrage nur in US-Dollar an, wennauch Ihre 6rtliche Landeswihrung US-Dollar ist.

Studien kosten1 Geben Sie die Wahiung an, die zur Beantwortung der unten 1.

aufgefuhrten Fragen verwendet wird (z. B. Euro, Pesos, etc.)

2 Geben Sie den voraussichtlichen Gesamtbetrag fur die iahriichen Studiengebiihren an 2.Studiengebiihr: Zu zahlende Gebiihr fur dietatsachliche Teilnahme am Studium (Kurse/Unterricht).Diese Gebfihr ist in der Regei wesentlich h6her alsdie Aiimeldegebiihr. In einigen Landemwerden keine Studiengebuhren berechnet

3 Geben Sie den voraussichtlichen Gesamtbetrag der Anmelde-/Einschreibegebfihren an: 3 Hinweis.Anmelde-/Einschreibegebiihr: Eine Gebiihr, die fur den venualtungstechnischen Fur dieseAufwand der Schule/Hochschuie zur Anmeldung bzw Einschreibung des Studierenden . - .erhoben wird. Diese-Gebfihr ist in der Regel wesentiich niednger als die Studiengebuhr -Elrltrage Smd

spater Belege4 Geben Sie den voraussichtlichen Gesamtbetrag der Kosten fur Unterrichtsbiicher an 4. GIUZUFBICIWH

5. Geben Sie den voraussichtlichen Gesamtbetrag der Kosten fur die Nutzung von Laboren an: 5

6. Geben Sie den voraussichtlichen Gesamtbetrag der Kosten fur Lemmatenalien an 6

7. Geben Sie den voraussichtlichen jahriichen Gesamtbetrag fur sonstige Gebuhren anGebuhr (bitte erlauiern): 7aGebuhr (bitte erlautern) 7bZwischensumme (bitte Zeiien 2-7b addieren): "

Sonstige Gebiihren

1 Geben Sie den voraussichtlichen jahriichen Gesamtbetrag der Kosten fur Coaching/Tuiorin an 1- -*T* - * vi- ---- - -l -l- - ---*ll -I-i-* T 9-1 -- -- - -. ---- .. D2 Geben Sie den voraussichtlichen iahrlichen Gesamtbetrag der Unterkunfls- und Verpflegungskosten an 2

3 Geben Sie den voraussichtlichen Gesamtbetrag fur Verkehrsmittel an 3.

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Ihr Antrag wird nur beriicksichtigt, wenn Sie ihn zusammen mit den folgenden Unterlagen einreichen:

Oflizieller Nachweis iiber die jiihriichen Studiengebiihren der Schule oder Hochschule, die der Bewerber im niichsten

Studienjahr besuchen m6chte, ohne Unterkunfts- und Verptiegungskosten, Kosten fur Verkehrsmittel oder Kostenfiir Tutoring/Coaching. Bitte bringen Sie eines der folgenden Dokumente bei:

- Aufgeschlusselte Kosten auf einem Dokument mit offizieilem Brietkopf der Schule/Hochschule

- Kosteninformationen in einer Broschiire der Schule/Hochschule (Papierversion oder Ausdruck der Webseite derSchule/Hochschule)

- Rechnung der Schule/Hochschule- Belege des vorherigen Schul-/Studienjahrs (wenn der Studierende dieselbe Schule/Hochschule wie im

vergangenen Jahr besucht)

Nachweis, dass der Studierende an"eirrer Einrichtung zur weiterfuhrenden Bildung angemeidet ist Bitte bringen Sie

eines der folgenden Dokumente bei:

- Den Ietzten Leistungsnachweis des Studierenden

- Dokument, welches die Immatrikulation des Studierenden beiegt, wie ein Brief der Schule/Hochschule oder einSchiiIer-/Studierendenausweis

Kopien der Informationen zum Mitarbeitereinkommen (einschhefilich Einkommen aus der Bescheftigung bei Abbott,

Rentenbeztigen und Einkommen aus seibstendiger Arbeit)

Kopien der Einkommensinformationen fiir alle anderen Personen, die den Studierenden tinanzieil unterstutzen. FurPersonen, fiir die Sie das Einkommen nicht nachweisen konnen, fullen Sie bitte das Formular "Certiication ofUndocumented Income" (Bescheinigung Liber nicht dokumentiertes Einkommen) aus, weiches bei derPersonalabteilung erheltlich ist, und unterzeichnen Sie dieses.

Belege aus einem vorherigen Stipendium.MDies betrifft nur Studierende, die bereits in einem vorigen Jahr einStipendium der Foundation erhalten haben. lhrem Antrag ist ein Zisetzliches Formular beigefiigt, Vvenn-Sie Belegeeinreichen miissen. (Bitte nicht beachten, wenn Sie diese Belege bereits oben im Zuge der offiziellenKostendokumentation beigefiigt haben.)

1

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Die in dieselm Antrag gemachten Angaben sind nach meinem besten Wissen und Gewissen korrekt und vollstz"-Lindlg.. Durch

die Unteizeichnung dieses,Antrags gestatte ich der Clara Abbott Foundation (der Foundation), alle notiaen Informationeneinzuholen die sie fur die Uberprufung der Korrektheit der Angiaben in diesem Antrag fur notwendig ha . Mit meinerUnterschnft gestatte ich der Clara Ab-bott Foundation, sich an ie Schule/Hochschule des Studierenden zu wenden,.umweitere Informationen uberhden Studierenden einzuholen: Ich bin mir bewusst, dass meme personlichen Daten anudie

Foundation in den USA weiter?1eleite,t werden und dass die in den USA geltenden Gesetze .eventuell nicht den gleichenUmfanom an Datensichutz vorse en wie die Gesetze meines Wohnlandes. Die Foundation wird iedoch alle angemessenenMallna men ergreifen, um meine personlichen Daten zu schutzen.

Die Foundation duldet keinen Betrufg, Tauschung oder Verschleierung im Hjnblick auf die in diesem Antrag EemachtenAngaben. Sollte die Foundation fes stellenhdass ein solches Verhalten vorliegt, ist sie-lberechtiglt iegliche a tuellen oder ausstehenden Antrage abzulehnen, sowie in Z-ukunft keine weitere Forderung zu gewahren."Bei Mitarbeitern von Abbott wirdein solches Verhalten als ein V-erstol"$ gegen die Abbott-Richtlinien zum Verhalten im Geschattsleben (Code of BusinessConduct) betrachtet und unterliegt den darin vorgesehenen Maltinahmen.

Die der Foundation iiberlassenen Informationen werden streng vertraulich behandelt, soweit es das Gesetz nicht andersfordert. Die Foundation ist berechtigt, Antrage auf Unterstutzung nach eigenem Emiessen abzulehnen.

Mit meiner Untersphrift bestatige ich, dass ich die Checkliste in Abschnitt 5 dieses Antrags ausge-fiillt ulnd .die erbetenen

Uhnterlargen angiifugtthabe. Die ieweiligen Daten und Betrage habe ich auf den Dokumenten, die ich mit diesem Antrageinreic e, einge reis .

Unterschrift des Studierenden (oder des Mitarbeiters /m Ai/#rag des Stud/erenden) Datum

Unterschrift des Mitarbeiters (Ob//gator/sch) Datum

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GBE Gzmz

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CASP Internatlonaler Antrag V 5/08

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.- 1 Abboitpensionarsegh. BeiApbou3Pehsionqren1hahueii I Abuoigmriarbeifgrntbdergeeiisioriarenj *lf *eg*" iiesifeich um%Mitarbeiter, die mindes"tens:50 Jahre alt ff ii? DaSfProgramm,gtehtStie4Qcflcingiem4offen&5 wehnqsf lwf%*sinfg*,ur34dmindeetenks10*Jahre-belmiuntemgthmen Q xi , M1 dJ",ese,irln$selbeniHaushaltQeben oderudlgr Abbott-, y,bqgghamgr warefi. Enem"aiige"Mriarbeiierj gre diese" . .Q , Pfmgfarqeirer cue?-Pensrbharlnaupisfacniraffiruf2?? .ff

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l Die Arbeitswiert des Mitarbeiters muss mindeetens 20 *X* r hi-if X 2 alterale 24*-Jahre?"z*$lt*"seinzA V N AX X -5%" ( H ) 5 X : u 4 -f X 45,/ : t 1,, eff? i V V Q ,xv N , fgf Stunden pro Wochebetragen: 5, 1 1? 1 55 .3-tg. ,G

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HINWEISE ZUR BEANTRAGUNG

1. Ftillen Sie die Abschnitte 1 bis 6 dieses Antragsformulars vollstandig und in Druckbuchstaben (keine Schreibschrift) aus.Beantworten Sie samtliche Fragen.

2. Fiigen Sie die in Abschnitt 5 in diesem Antrag genannten erforderlichen Unterlagen bei.

3. Versehen Sie diesen Antrag-infAbschnitt 6 mit den erforderllchen Unterschriften.

4. Senden Sie diesen Antrag und die zugehorigen Unterlagen bis zum internen Anmeldeschluss der Tochtergesellschaft an denzustandigen Mitarbeiter Ihrer Personalabteilung vor Ort zuriick. Antrage, die nach diesem Datum eingehen, k6nnen Ieidernicht berucksichtigt werden.

Hinweis: Alle Bewerber, die ein Stipendium erhalten, mussen Belege iiber samtliche Sludiengebiihren beibrlngen, bevor sie sichfur ein weiteres Stipendium bewerben. Ihre Personalabteilung wird Sie informieren, wann Sie die Belege einreichen sollen. DieSumme der Belege muss mit dem Betrag des Stipendiums iibereinstimmen. Sollten diese Belege nicht vorgelegt werden, wird diegesamte Familie des Abbott-Mitarbeiters von allen zukiinftigen Stipendien und Leistungen der Clara Abbott Foundationausgeschlossen.

*- -Fragen-oder Anmerkungen?-Wenden-Sie-sich an einen Mitarbeiter-Ihrer Personalabterlung-vor Ort oder-besuchen Sie dle-Webseite--- - -

wr Clara Abbott Foundation unter http://c/ara.abb0tt.com. J

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8-stelhge UPI-Nummer des Mitarbeiters(Wenden Sie such an HR, wenn Sue Ihre Nummer mcht kennen)

Nachname des Abbott-Mitarbeiters Vomame des Mitarbeiters Wohnland des Mitarbeiters

Geburtsdatum des Mltarbeiters Elnstellungsdatum des Mitarbeiters(TT/M MIJJ) (TT /MM/JJ) (IT/MM/JJ)Datum der Beendlgung des Arbeltsverhiltnlsses

Berufsbezeichnung des Mitarbeiters Abteilung des Mltarbeiters Einsatzort des Mrtarbeiters (Stadt)

Telefonnummer des Mitarbeiters (gesch ) Telefonnummer des Mitarbeiters (priv.)

Status des Mitarberters: Aktiv Im Ruhestand Datum use Ruhesxandamnns (Tr/MM/JJ) tn Drensqahre

Mitarbeiter mit Iangfristiger Arbeitsunfiahigkeit Verstorben Mitarbeiter mitfbetristetem VertragNorubergehend Beschiftigter

Famillenstand des Mitarbeiters: Ledig Verheiratet Gesetzlich getrennt Geschieden Verwilwet

1 Mrtarbeiter.

2. Ehepartner"

3. Studierender

Gesetzlich adoptierte/r Sohn/Tochter Sonstige (bitte angeben)

Nachname des Ehepartners des Mltarbeiters Vomame des Ehepartners des Mitarbeiters Bemfsbezeichnung des Ehepartnersdes Mitarbeiters

In WeIChBI" B8ZIShUng SIBIIBD SIB ZU dem ADIJOIZI-MIIBFDEIIET? B/ite beac/:ten S/e, dass der Bewerber ern unter/7a/lsberec/rbgtes /Gnd(24 Jahre oder/:Inge/7 se/n und /n e/ne der urrten augyehihrren Kalegonen fa//en muss

LeIbIIChe/F SOI1I"t/TOChIEI" SIIefSOhn/-IOCI1 ter (Muss be/ Abbott-M/tarbe//er wohnen oder dieser hauptsidr//ch li/r se/nenihrenUnterha/I veranlwo/"H/ch se/n)

Wlrd der Studlerende ln irgendeiner Form vom Abbott-Mltarbelter fmanzlell unterstutzt"7 Ja Nein

Wrrd der Studlerende In irgendeiner Form vom anderen Ieiblichen Elterntell tinanzlell unterstulzt (d. h Unterhaltszahlungen etc )? Ja Nein

Bitte fullen Sie die unten stehende Tabelle aus (T ragen Sie unter ,,Mitarbeiter" sich selbst ein).

Name Alter Beziehung zum Abbott-Mrtarbenter

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Alle tinanziellen Angaben MUSSEN in der Wz"-ihrung des Landes erfolgen, in dem der Abbott-Mitarbeiter sein Gehalt bez"eht.Geben Sie Betrige nur in US-Dollar an, wenn auch Ihre 6rtIiche Landeswihrung US-Dollar ist.

1. Geben Sie die Wiihrung an, die zur Beantwortung der unten aufgefiihrten Fragen verwendet wird (z. B. Euro, Pesos, etc.)

1.

2. Gesamtjahresbruttoeinkommen des Abbott-Mitarbeiters fiir das Jahr 2007 oder 2008

2.

3. Wenn Sie sich im Ruhestand beiinden, geben Sie bitte die entsprechende Rentenhohe oder sonstige Unterstiiizungsgelder an

3.

4 Gesamtjahresbruttoeinkommen des anderen Ieibiichen Eiterntells fiir das Jahr 2007 oder 2008

4.

5. Gesamtjahresbruttoeinkommen des mit dem Abbott-Mitarbeiter verheirateten Stiefeiternteilsiilr das Jahr 20207 oder 2008

5.

6. Gesamtjahresbruttoeinkommen des mit dem anderen Ieibiichen Elternteil verheirateten

Stiefeltemteris fiir das Jahr 2007 oder 2008 6

7. Giisamtyahresbruttoeinkommen des Witvvers/der Witwe des Abbott-Mitarbeiters fur das Jahr 2007 oder 2008" 7.Bruttoeinkommen bedeutet das Gesamteinkommen aus allen Bezugsqueilen, einschlielklich Gehalts-, Bonus- undLeistungszuzahlungen vor Abzug von Steuern oder sonstigen Abgaben.

Bitte geben Sie sonstige Unterhaltsberechtigte an, die im Haushalt des Mitarbeiters leben oder fur deren Unterhalt dieserhauptsechlich verantwortiich ist:(Die im vorherigen Abschnitt angegebenen Personen mlissen nicht erneut aufgefuhrt werden.)

Name Alter Beziehung zum Abbott-Mitarberter

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I K Hat der Studierende einen ersten Biidungsabschluss (vierjffihriges Studium) an einer Hochschule en/vorben"? 4.

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Wohnland des Studierenden Geburtsdatum des Studierenden (Ti/MM/JJ)

Telefonnummer des Studierenden

Familienstand des Studierenden: (B/me Enspremendes an/rreuzen)

Ledig Verheiratet Geschieden Verwitwet Gesf-.ziicii getfennt

Bitte geben Sie den hbchsten Schulabschluss Ihrer Mutter an.Mittlerer Schulabschluss weiterfiihrende AusbildungAbitur/Fachhochschuireife Hochschulabschluss (vierjz1ihrigerStudiengang)

- Bitte geben Sie den h6chsten Schulabschluss lhres Vaters an.Mittlerer Schulabschluss weiterfiihrende AusbildungAbitur/Fachhochschulreife Hochschulabschluss (vierjffihnger Studiengang)

1 Sind Ihre Ieiblichen Eltern miteinanderverheiratet? 1.

2 Betindet sich der Studierende zurzeit im Ietzten Jahr seiner Ausbildung in der weiterflihrenden Schule? 2.

3. Hat der Studierende die weiterfuhrende Schule abgeschlossen? 3.

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Vollstandige Bezeichnung der Schuleli-lochschule, Standort der Schule/Hochschule (Stadt)die der Studierende besuchen m6chte(Bitte geben S/e den vol/sta"nd1gen oiiiz/e//en Namen der we/Ie/7?/h/enden B//dungse/nnchtung an)

Voraussichtliches Ausbildungsende fiir ersten Landweiterfiihrenden Abschiuss (TT/MM/JJ)

Fachrichtung

VORAUSSICHTLICHE GESAMTKOSTEN PRO STUDIENJAHR

Bitte geben Sie den entsprechenden Betrag in der Wahrung des Landes an, in dem der Abbott-Mitarbeiterl-Pensionar seinEinkommen beziehtlbezog (NICHT des Landes, in dem der Bewerber studiert). Geben Sie Betrige nur in US-Dollar an. wennauch Ihre Eirtiiche Landeswihrung US-Dollar ist.

Studienkosten1 Geben Sie die Wahrung an, die zur Beantwortung der unten 1

aufgefiihrten Fragen verwendet wird (z B. Euro, Pesps, etc.)

2. Geben Sie den voraussichtlichen Gesamtbetrag fur die iahrlichen Studiengebiihren an. 2.Studiengebfihr: Zu zahlende Gebfihr fiir dietatsachliche Teilnahme am Studium (Kurse/Unterncht).Diese Gebfihr ist in der Regei wesentlich h6her alsdie Anmeidegebiihr In einigen Landemwerden keine Studiengebiihren berechnet

3. Geben Sie den voraussichtlichen Gesamtbetrag der Anmelde-/Einschreibegebihren an: 3 Hinweis.Anmeide-/Einschreibegebiihr: Eine Gebiihr, die ffir den verwaltungstechnischen Fir dieseAufwand der SchulelHochschuIe zur Anmeldung bzw. Einschreibung des Studierenden . - .erhoben wird. Diese Gebfihr ist in der Regel wesentiich niednger als die Studiengebuhr *Elflgtrage smd

-spater Belege4 Geben Sie den voraussichtlichen Gesamtbetrag der Kosten fiir Unterrichtsbiicher an 4. GIHZUFGICIWH

5 Geben Sie den voraussichtlichen Gesamtbetrag der Kosten ffir die Nutzung von Laboren an 5

6 Geben Sie den voraussichtiichen Gesamtbetrag der Kosten fur Lernmaterialien an: 6.

7 Geben Sie den voraussichtlichen iahrlichen Gesamtbetrag fur sonstige Gebiihren anGebiihr (bitte erlautem) 7a.Gebiihr (bitte erIautern)" 7bZwischensumme (bitte Zeilen 2-7b addieren): ""

Sonstige Gebihren- - - - - 1. .Geben Sie den voraussichtlichen iahriichen Gesamtbetrag der,Kosten ffir,Coaching/Tutoring an*--- --1. - -- - --

2. Geben Sie den voraussichtlichen jahrlichen Gesamtbetrag der Unterkunfts- und Verptiegungskosten an 2

3 Geben Sie den voraussichtiichen Gesamtbetrag fur Verkehrsmittel an 3

-ii"."it-so-:iid etitggeeu -Q E 6-HM, e ,- 1-. .lib - Sie

WICHTIGI

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Ihr Antrag wird nur bericksichtigt, wenn Sie ihn zusammen mit den folgenden Unterlagen einreichen:

Ofiizieller Nachweis iiber die j"ahrlichen Studiengebiihren der Schule oder Hochschule, die der Bewerber im nichsten

Studienjahr besuchen mbchte, ohne Unterkunfts- und Verpflegungskosten, Kosten fiir Verkehrsmittel oder Kostenftir Tutoring/Coaching. Bitte bringen Sie eines der folgenden Dokumente bei:

- Aufgeschiiisseite Kosten auf einem Dokument mit ofhzieliem Brieikopf der Schule/Hochschule

- Kosteninformationen in einer Broschiire der Schule/Hochschule (Papierversion oder Ausdruck der Webseite derSchule/Hochschule)

- Rechnung der Schule/Hochschule- Belege des vorherigen Schul-/Studienjahrs (wenn der Studierende dieselbe Schule/Hochschule wie im

vergangenen Jahr besucht)

Nachweis, dass der Studierende an einer Einrichtung zur weiterfiihrenden Bildung angemeldet ist. Bitte bringen Sie

eines der folgenden Dokumente bei:

- Den Ietzten Leistungsnachweis des Studierenden

- Dokument, welches die Immatrikulation des Studlerenden belegt, wie ein Brief der Schule/Hochschule oder einSchiiler-/Studierendenausweis

Kopien der Informationen zum Mitarbeitereinkommen (elnschlielilich Einkommen aus der Beschiiftigung bei Abbott,

Rentenbezligen und Einkommen aus selbstiindiger Arbeit)

Kopien der Einkommensinformationen fiir alle anderen Personen, die den Studierenden inanzieil unterstiitzen. FiirPersonen, fur die Sie das Einkommen nicht nachweisen konnen, fullen Sie bitte das Formular ,,Certitication ofUndocumented Income" (Bescheinigung iiber nicht dokumentiertes Einkommen) aus, welches bei derPersonalabteilung erhi-iitlich ist, und unterzeichnen Sie dieses.

Belege aus einem vorherigen Stipendium. Dies betrifft nur Studierende, die bereits In einem vorigen Jahr ein

Sitipendium-d& Foundetion erhalten hatierfmremmrag ictl-:I-E zusatilihes Formular beigefugtf wenn Sie Belege - 7einreichen miissen (Bitte nicht beachten, wenn Sie diese Belege bereits oben im Zuge der oftiziellenKostendokumentatlon beigeftigt haben.)

., .,,.,.$..i ,.Die in diesem Antrag gemachten Angaben sind nach meinem besten Wissen und Gewissen korrekt und vollstandigi Durch

die Unteizeichnung dieses.Antrag.s gestatte ich der Clara Abbott Foundation (der Foundation), alle notiaen lnformationeneinzuholen die sie fur die Uberprufung der Korrektheit der Angaben in diesem Antrag fur notwendig ha . Mit meinerUnterschrift gestatte ich der Clara Abbott Foundation, sich an die Schule/Hochschule des Studierenden zu wenden .umweitere Informationen uberhden Studierenden einzuholen: lch bin mir bewusst, dass meme personlichen Daten anldie

Foundation in den USA weiteroleleite-t werden und dass die in den USA geltenden Gesetze .eventuell nicht den gleichenUmfandl an Datenschutz vorse, en wie die Gesetze memes Wohnlandes. Die Foundation wird iedoch alle angemessenenMaliina men ergreifen, um meme personlichen Daten zu schutzen.

Die Foundation duldet keinen Betrufg, Tauschung oder Verschleierung im Hlinblick auf die in diesem Antrag EemachtenAngaben. Sollte die"Foundation fes stellen,- dass ein solches Verhalten vorliegt, ist sielberechhgtmegliche a tuellen oder Iausstehenden Antrage abzulehnen, sowie in Zukunft keine weitere Forderung zu gewahren .Bei itarbeitern von Abbott wirdem solches Verhalten als ein Verstolt gegen die Abbott-Richtlinien zum Verhalten im Geschaftsleben (Code of BusinessConduct) betrachtet und unterliegt den dann vorgesehenen Mallnahmen.

Die der Foundation iiberlassenen lnformatjonen werden streng vertraullch behandelt, soweit es das Gesetz nicht andersfordert. Die Foundation ist berechtigt, Antrage auf Unterstutzung nach eigenem Ennessen abzulehnen.

Mit meiner Unterschrift bestatige ich, .dass ich die Checkliste in Abschnitt 5 dieses Antrags ausgefiillt und .die erbetenen

Uhnterlahgen angiifugtthabe. Die ieweiligen Daten und Betrage habe ich auf den Dokumenten, die ich mit diesem Antrageinreic e, einge reis .

Unterschrift des Studierenden (oder des Mitarbeiters im Au/Wag des Studierenden) Datum

Unterschrift des Mitarbeiters (OD//gator/sch) Datum

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" I candidati idexionogaveileoihpletatdiild 3%uola ls-pphefiore e"devono aver intenzione difi*eqiientar,e$ to idcyiyersi) ad i1rK1-prqog/i*amrg1*aJV), , , - f,scolastlcotdg hvelloiuniversitario pigesso 1fezf .-me, If it . *1-. , N1. W. .* mf Aunn5er$1tag ijscuole professlonak ollsututl dr J *

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di borsa di studio.

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2. Allegare tutta la documentazione richiesla,vedi lo Step 5 del formulario.

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ISTRUZIONI PER LA COMPILAZIONE DEL FORiVlULARiC5

1. Completare tutti i campi del formulario. Eirichiesta una risposta a tutte le dornande.

-4. Consegnare il formulario debitamente compiiato efpmvvisto di tutla la necessaria documentazione al vostro rappresentantelocale HR entro la data di scadenza sopra nportata.l formulari conseganti in ritardo non verranno presi in considerazione.

Nota bene: Tutti i candidati che hanno ricevuto una borsa di studio per Piscrizione ad un determinato annoaccademico, sono tenuti a documentare, alla fine dell*anno scolastico stesso, tutte le ricevute deipagamenti delle tasse universitarie. Gli importi di tali ricevute dovranno corrispondere a quelli indicatinella documentazione ufflciale ottenuta dalla scuola e allegata al presente formulario di paxtecipazione

Domande o commenti?Contatta ll tuo rappresentante delle risorse umane o vislla ll sito web http://c/ara.abbott.com della Clara

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Numero (UPI) delllmpiegato parl ad 8 numeri(Per magglon Info oontaltare le HR))

Cognome del dlpendente Nome del dipendente Nazione di appartenenza

Data dl nascita del dipendente (GG/MM/ANNO) Data di assunzione (GG/MM/ANNO) Data rlsoluzione rapporto dl lavoro(GG/MM/AA)

Mansione del dlpendente Dlvisione dlappartenenza Afiliata di appartenenza (Citte)

POSIZi0ne Iavorativa" AIIIVO PGHSIODBIO Data Pens1onamento(GG/MM/AA) - Anm dl servlzlo

Dipendente con invalldite prolungata Deceduto A contratto

Stato clvile: Single Sposato Legalmente separato Divorziato Vedovo

Cognome coniuge dipendente. Nome coniuge dipendente Mansione deol coniuge

GFBCIO di FSIBZIOHB COD II dIp&l"1dEnIB AIJbOII? Ca/ara che fa/mo /Ich/esta dl barsa d/ tud/a devono essere ligl/ de/d/pendente (dl eta par/ 0/nllenare a 24 ann/) appartenenb ad una de//e categone sotto nportvte

fIgIlO/3 nafurale IIQIIO/8 BCQUISIIO (manlenuto da/d/pendenle ABBOTT)

flglio/a legalmente adottato altro (spiegare)

Lo studente riceve qualche tipo di aiuto economico da parte del dipendente della Abbotl? Yes No

L0 studente riceve qualche tipo di aiuto economico da parte dell*altro suo genitore naturale? Yes N0

Elenco delle persone a carico del dipendente Abbott (il dipendente deve essere incluso).

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Tutte Ie richieste su informazioni Enanziarie DOVRANNO essere inserite nella valuta del paese di appartenenzadove il dipendente riceve il suo stipendio.Non inserire importi in dollari U.S.

1. lnserire la tipologia dl valuta utilizzata per Ia compilazione (es Euro, Pesos, ecc.). 1.

2. Reddito totale annuale lordo per Vanno 2007 o 2008 del dipendente Abbott 2

3. Se sei un pensionato Abbott inserire llimporto della pensione corrisposta 3

4. Reddito totale annuale lordo per l*anno 2007 o 2008 deII"altro genitore naturale 4

5. Reddito tot annuale lordo per I"anno 2007 o 2008 del genitore acquislto sposato can it dlp Abbott 5

6. Reddito totale annuale lordo 2007 o 2008 del genitore acquisito sposato con altro gen naturale 6.

7. Reddito totale annuale lordo 2007 del vedova/o del dipendente Abbott 7.

II reddito totale annuale lordo e rappresentato da ogni tipo di risorsa incluso stipendio , incentivi,indennith esenti da qualsiasitrattenuta.

Indicare Ie persone a carico che vivouo nella stessa casa del dipendente e che sono da lui mantenute economicamente(non includere i nomi giii riportati sopra)

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Stato "civiie"

1. I tuoi genitori sono sposati tra di Ioro? 1.2. Stai attualmente frequentando l*ultimo anno di scuola superiore?

3. Hai completato la scuola superiore?

4. Hai ottenuto una Iaurea universitaria di primo livello?

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Cognome dello studente Nome dello studente Secondo nome

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PRIMA DI COMPILARE IL FORMULARIO LEGGERE TTEI

UTTE LE ISTRUZIONI SULLA PRIMA PAGINA

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Nome della scuola che lo studente desidera 6-equentare(Dovrd essere rzportato :I name ujficiale dell "istztuto

Data programmata per 11 conseguimento della laurea(GG/MM/ANNO)

Area di studio

lnserire gli importi nella valuta in cui il dipendente/pensio

Costo dell*universita

1. lnsenre il tipo di valuta usata per 1.oompilare le seguenti informazioni(es. Euro, Pesos, etc)

2. lnserire costo totale annuaie stimato

per letasse Universitarie. 2.Per tasse si intendono i costi per pagare lafrequenza c/o Vistituto universitario(corsi/lezioni).Solitamente le tasse sono piu elevate

. nspetto all"importo da pagare al momento delliscrizione.In alcuni paesi le tasse sono gratuite.

lnserire ll costo totaleper ie tasse d"iscrizione: 3-l-Tasse d"iscrizione: Tassa associate ai costi amministrativi

dell"istituto dove Io studente intende iscriversi.

Qusto tipo di tasse e solitamente inferiore rispetto alleTasse Universitarie

4. lnserire il costo totale annuaie stimato per spese 4.relative ai llbri.

5. lnserire il costo totale annuaie stimato per spese: 5di laboratorio

6. lnserire il costo totale annuaie stimato per spese : 6.

Costo totale annuaie stimato per le spese scolastiche

studente sta studiando).Non lnserire importi in dollari U.S.a meno che la valuta che ricevete sia in dollari U.S.

Indlrizzo dell*Ur1iversita(Citta)

Paese dell"Universita

nato viene retribuito (Non considerare il luogo dove lo

- Nota bene:Tutte le ricevute saranno richieste, in futuro

.-----".---diaccessori - -Y2.---- --.- -i---.-s--.- -.---- ---- --..2-.--W7. lnserire il costo totale annuaie stimato per altre spese:

Tasse (descrivere la tipologia) 73Tasse (descnvere la hpologia) 7bTotale(sommare tutti gli importi):

Altro tipo di tasse

1. lnserire costo totale annuaie stimato per tasse di ripetizioni1.

2. lnserire costo totale annuaie stimato per aftitto. 23 lnserire costo totale annuaie stimato peril trasporto 3.. & /

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Nel caso in cui non dovessi allegare la documentazione di seguito descritta la tua richiesta non saria presa inconsiderazione.

Documento uFE1ciale riguardante le tasse Universitarie dellilstituto che Io studente intende frequentare per ilprossimo anno. Eccetto alloggio (ahitto), trasporto,spese per ripetizioni , Allegare almeno una ricevuta delle seguenti:

- Iista dei costi riportata su carta intestata delI"istitutof Costi dettagliati su brochure (carta o copie stampate dal sito web delI*Istituto universitario)- Ricevute del pagamento delle tasse- Rioevute relative all"anno precedente (se Io studente sta ancora frequentando Io stesso Istituto)

verificare che Io studente sia iscritto c/o un Istituto Universitario.Fornire uno dei seguenti documenti:- Risultato ultimi esami sostenuti- Documenti oomprovanti liscrizione o su carta intestata o tramite tessera didentiicazione

Copia delle informazioni sul reddito annuale lordo del dipendente (incluse pensioni,ed ogni altro tipo di entrata)

Copie del reddito di tutti coloro che provvedono al supporto dello studente.Per coloro che non sono in grado difomire-tale documentazione ,siete pregati di compilare e iirmare I*Autocertificazione di redditoallegatazaleformulario. -- - --Ricevute relative aIl*anno precedente.TaIe documentazione e nchiesta a tutti gli studenti che hanno gie ricevuto altre

borse di studio da parte della Fondazione.Se saranno richieste altre ricevute di pagamento un ulteriore form safeincluso al formulario. *

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Garantisco che le informazioni presenti in questo formulario sono veritiere e corrette. Nel iirmare questo formulario

conferisco alla Clara Abbott Foundation(La fondazionel il Kaotere di verificare la veridicita di quanto dicharato. Sonoconsapevole che i miei dati pesonali saranno inoltrati al a bbott negli U.S. e che gli U.S. Irjotrebbero non avere leggiche proteggono i miei datidpersonali aventi l*identico contenuto delle leggi del mio paese. a Abbott prendera ledovuteprecauzioni al fine 1 proteggere i miei dati persouali

La fondazione non tollerera alcun tipo di truffa, falsita ed occultamento riguardo le informazioni contenute nel presenteforrnulario. Se la fondazione riterra che qualcuno sia incorso in tale comportamento potra negare le richieste di borsa distudio. Per gli impiegati Abbott qualunque dei presenti comportamenti verra considerato violazione del Codice di CondottaAbbott e saxanno soggetti alle conseguenze previste dal codice.

Le informazioni fornite alla Fondazione saranno considerate confidenziali eccetto quanto previsto dalla legge. Lafondazione potra negare qualsiasi richiesta di assistenza a sua descrizione

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INFORMACJE DOTYCZACE WNIOSKU

1". "Wypeilnij-kompletnie vmiosek od Kroku 1 do Kroku 4. Odpowiedz ua wszystkie pytania.

2. Dolqcz wymagane dokumenty jak to zostaio wyszczeg6lowione w Kroku 5.

3. Zh5Z wymagane podpisy w Kroku 6 niniejszego wniosku.

4. Przekaz wniosek i dokumcntacjg uzupelniajqcq do lokalnego biura Dziahl HR przed upiywem terminu ziozenia wniosku,obowiqzuj qcym wewnqtrz danej sp6iki. WNIOSKI ZLOZONE PO TERIVIINIE NIE BEDA ROZPATRYWANE.

. Uwaga: Wszyscy wnioskodawcy, kt6rzy otrzymajq stypendium, muszq dostarczyci potwierdzenie wszelkichdotychczasowych koszt6w, w celu ponownego ubiegania sig 0 stypendium. Tw6j przedstawiciel Dziahx HR poinformuje Ciq,kiedy przedstawid stosovsme dowody opiat. Potwierdzenia te muszq byci zgodne z przyznanq kwotq stypendium.Niedostarczenie potwierdzeli spowoduje brak mozliwoici zakwalifxkowania sig na stypendium Fundacji Clary Abbott wprzyszioici.

Masz pytania lub uwagi? Skontaktuj sig z przedstawicielem lokalnego Dziahl HR lub zajrzyj na strong iiitemetowq Ifundacli- *-- - -- - -Cla1**y*AlBbEtTfacTdfzidi7&sT1i1 hftb://Elafabbif -A A "W 7* F- *A - A D - & /

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PROSZE WYPELNIAC DRuKowANYMl LITERAMI

Nazwisko pracownika iirmy Abbott hniq pracownika Kraj pracownika

Data urodzenia pracownika (DD/MM/RR) Data zalrudnienia prac. (DD/MM/RR) Data rozwiqzania umowy (DD/MM/RR)

Stanowisko pracownika Dzial pracownika Miejsce pracy pracownika (miasto)

Kod statusu pracownika: O Aktywny O Na emeryturze Dara przejicla na emerymrg (DD/MM/RR) lam pracy

O Pracownik na dlugim zwolnieniu chorobowym O Zmarly O Pracownikkontraktowy/czasowy

Stan cywilny pracownika: O Kawaler/panna O Zonaty/mqiatka O W separacjiO Rozwiedziony/-a O Wdowiec/wdowa

Nazwisko malzonka pracownika Imiq malzonka pracownika Stanowisko malionka pracownika

Okfeil SWO-iq Telacjq Z pI"aCOWI1ikiCIIl flrmy AbbOtI. Uwaga wrlzoskodawca must by6 dzleclaem (do 24 lat) pozaslajqcym na utrzymanlu,w jednej zponzzszych kaiegom.

O R0dZOI"ly Syn/C6I"ka O Pasiefb/pa5iCI"biC3 (mum mzeszkai z pracownzklemfirmy Abbott lub pozaslawazf najego ulrrymamu)

O Adoptowany syn/c6rka O Inna (wyjainij)

Proszg wypelnii poniiszq informacjg:

Nazwisko Wick Relacja wobec pracownika flrmy Abbott1. Nazwisko pracownika:

2. I*IizxlviEkoYE1-glionlc-23:

3. Nazwisko studenta:

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Wszystkie wymagane informacje iinansowe MUSZA zostai wprowadzone w walucie kraju, w ktdrym pracownik firmyAbbott otrzymuje Wynagrodzenie. Nie wpisuj kwot W walucie amerykafnskiej, chyba ie lokalnq walutq Twojego kraju sqdolary amerykaliskie.

1. Proszg podad walutq (np. Euro, Peso itd.)

2. Calkowity roczny dochod brutto pracownika fu-my Abbott w 2007 lub 2008 roku 1.

3. Jczelijcstei cmerytowanym pracownikjem frrny Abbott, podaj emeryturq 2.lub inne otrzymywane iwiadczenie

4. Caikowity roczny dochod brutto innego rodzica biologicznego w 2007 lub 2008 roku 3.

5. Caikowity roomy dochod brutto ojczyma/macochy jako maizonka/-i pracownika 4flrmy Abbott w 2007 lub 2008 rolcu

6. Calkowity roczny dochod brutto ojczyma/macochy jako maizonka/-i innego 5rodzica biologicznego w 2007 lub 2008 roku

7. Caikowity roczny dochod brutto wdowy/wdowca po pracowniku 51-my Abbott w 2007 lub 2008 roku 6.

Dochod brutto oznacza calkowity doch6d ze wszystkich irodel, W tym - lecrniftylko - pensjg, premie i bonusy,-przed .wszelkitni odliczeniami.

Podaj inne osoby, mieszkajqce w gospodarstwie domowym pracownika i pozostajqce glownie na jego utrzymaniu:(Nic wpisuj nazwisk podanych w poprzedniej cz:g$ci.)

Nazwisko Wick Relacja z pracownikiem fu-my Abbott

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Nazwisko studenta Imiq studenta Drugie imiq

Kraj studenta Data urodzenia studenta (DD/MM/RR)

Stan Cywilny Stlldentat (zaznaczjednq apcjg)

O Kawaler/panna O Zonaty/mqiatka O Rozwiedziony/-a O Wdowiec/wdowa O W separacji

w jednej zpanuszych kmegunz

jego ulrzymamu)

O Adoptowany syn/cdrka O Inna(wyjas1nij)

OICICSI SWO-iq relaqjq Z pI"aCOWI1ikiCm EITIIY Abb0T1. Uwaga wmaskodawca mum byc" dzzecluem (do 24 lal) poznstajqcym na ulrzymamu,

O .R0dZDIly Syn/C(,)l"k3 O PaSiCl"b/paSiEI"biCa (musl mzeszkac" z pracawmlaem jirmy Abbott lub pozostawac" gl6wnze na

1. Czy Twoi biologicmi rodzice sq malzelistwem? 1. O Tak

2. Czy pracownik fLrmy Abbott zapewnia studentowi jakiekolwiek wsparcie fnansowe? 2. O Tak

3. Czy drugi rodzic biologiczny zapewnia studentowi jakiekolwiek wsparcie finansowe 3. O Tak(np. alimenty itp.)?

4. Czy jestei obecnie w trakcie ostatniego roku nauki w szkole iredniej? 4. O Tak

5. Czy ukoriczylei/-ai szkolq siredniq? 5. O Tak

O Nie

O Nie

O Nic

O Nie

O Nie

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Pelna nazwa szkoly, do kt6rej student planuje uczgszczai Lokalizacja campusu (miasto)(M-usz to byc" pelna, oficjalna nazwa szkoly wyzszej)

Planowa data uzyskania przez studenta Kraj, w kt6rym znajduje sig szkoiapierwszego dyplomu (DD/MM/RR)

Tematyka

SZACUNKOWE CALKOWITE ROCZNE KOSZTY NAUKI

Wpisz kwoty W walucie kraju, W kt6rym pracownik/emerytowany pracownik flrmy Abbottotrzymuje/otrzymywal wynagrodzenie (NIE W kraju, W kt6rym student sig uczy). Nie wpisuj kwot Wwalucie amerykaliskiej, chyba ie lokalnq Walutq Twojego kraju sq dolary amerykaxiskie.

Czesne1. Wpisz rodzaj waluty uiytej w odpowiedziach 1. il-1.

na poniZsze pytania (tjrEUR,-peso.itp.).2. Wpisz szacunkowe, calkowite roczne czesne: 2. .

Czesne: oplata do uiszczenia z tytulu uczgszczania do szkoiy (zajqcia/kursy). XOpiata ta jest zazwyczaj macznie wyzsza niZ opiata rejestracyjna.W niekt6rych krajach studenci sq zwolnieni Z czesnego.

3. Wpisz szacunkowy, calkowity koszt rejestracyjny: 3.Oplata rejestracyjna: opiata zwiaczana-z kosztarni administracyjnymi szkotyz tytuhl zapisania studenta. Opiata ta jest zazwyczaj znacznie nizsza niz czesne. Uwaga:

dla tych kwotnaleiy

dostarczyi4. Wpisz szacunkowe calkowite roczne koszty ksiazek: 4. % Potwierdzenia5. Wpisz szacunkowe calkowite roczne koszty lab.: 5.

6. Wpisz szacunkowe calkowite roczne koszty materiat6w: 6.

7. Wpisz szacunkowe calkowite pozostaie koszty: 7a.vb. JRazem (Proszq zsumuj linie 7a i 7b)Pozostale oplaty:

1. Wpisz szacunkowe calkowite roczne koszty korepetycji/prywatnych lekcji: 1.

2. Wpisz szacunkowe calkowite roczne koszty zakwaterowania i utrzymania: 2.3. Wpisz szacunkowe calkowite roczne koszty transportu: 3.& /

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Tw6j wniosek zostanie tylko wtedy rozpatrzony, jezeli bedzie zawier:-16 nastepujqce informacje:

E Oficjalna dokumentacja kosztdw ze szkoiy, do ktdrej student planuje uczeszczad w nadchodzacym rokuszkolnyrn, z wylqczeniem kosztdw zakwaterowania, transportu, korepetycji.

Przyjmowane sa nastepuj ace dokumenty:- Wyszczegdlnienie kosztdw na urzedowym papierze szkoiy- Wyszczegdlnienie kosztdw w broszurze szkoiy (w formie papierowej lub kopia wydrukowana ze strony

intemetowej szkoly)- Rachunek za uiszczenie czesnego

- Rachunki z zesziych lat (jesli student uczfgszcza do tej samej szkoly)

EI Dowdd na to, iz osoba jest studentem. Prosze dostarczye jedno z wybranych:

0 Ostatni raport ze studi6w

0 List ze szkoly potwierdzajacy, ze dana osoba jest na liscie studentdw lub identyfikator studencki

E Kopie zasiwiadczen o dochodach pracownika (w tym dochody z pracy w firmie Abbott, dochody emerytalne,dochody z samozatrudnienia itp.)

E Kopie informacji 0 dochodach wszystkich innych os6b zapewniajacych wsparcie finansowe dla studenta. Wprzypadku braku mozliwosici dostarczenia zaswiadczenia o dochodach, wypehiij i podpisz formularz zaswiadczeniao nieudokumentowanych dochodach, dostepny w dziale personalnym.

U Rachunki za wczesniejsze lata studidw. Ten punkt dotyczy jedynie studentdw, lctdrzy otrzymali dofmansowanie zF undacji w poprzednich latach. Jesli musisz dostarczyci rachunki za lata ubiegie dostepny jest dodatkowy formularz.(Jesli juz we wczesniejszej czesci dostarczyles te rachunki, zignoruj prosze te wiadomosci)

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Wedlug mojej najlepszej wiedzy, informacje zawarte w niniejszyrn wniosku sa kompletne i prawldlowe. Podpisujac niniejszywniosek, wyrazam zgodg na zasigganie przez Fundacjq Clary Abbott (Fundacja)wsze1k1ch informacji, ktdre Fundacja moze uzuao zakonicczne w celu zweryflkowania poprawnoici informacji zawartych w niniejszym wniosku Rozumiem, ze mojc dane osobowezostanq dostarczone do firmy Abbott w Stanach Zjednoczonych, oraz Ze pnepisy prawa, obowiazujape w Stanach Zjednoczonych,moga me chronid mojej prywatnoici w takun samym stopniu, jak prawo w moim kraju. Firma Abbott podejmie jednak wszelkleodpowiednie kroki w celu ochrony mojej prywamoici.Fundacja nie bqdzie tolerowari oszustwa, wprowadzama w blqd lub zatajenia odnoinie infomacji podanych w niniejszym wniosku.J ezeh Fundacja ustali, ze takie postqpowanie mjaio mlej sce, moze odrzucici biezacy lub oczekujqcy wniosek i moze odmowiriudzielania Jakiejkolwiek pomocy w pnyszioici W przypadku pracownikow fix-my Abbott takie postqpowanie bqdzie uwazane zanaruszcnie Kodeksu Postqpowama Biznesowego fu-my Abbott (Kodeks) i bqdzie podlegaxi konsekwencjom okreilonym w Kodeksie.Informacje dostarczone Fundacji bqda traktowane jako poufne z wyjqtkiem przypadkow, w ktorych prawo wymaga inaczej. Fundacjamoze odnucici proibq o pomoc wedhxg swojego wylqcznego uznania.

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Ddvidas ou comentarios?

Contate o seu representante do RH, ou o seu representamelocal da Funclaqio Clara Abbott no Brasll, ou v1s1Le o web sueda Fundagao Clara Abbott em http //clara.abbott.com T H E C L A R A A B B O T T F O U N D AT I O N

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os coriteng ladbs com Bolsas de titudos dovettifa ieientar os reclbos a ro fxados arftes de solfcitar novas bolsas de Estudos O seu

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- Y --fnInformagao Do , , ,, ,,Numero UPI (Unique Person Identifier) - 8 drgitos

(Contate o RH se voce nao sabe o seu numero)

Sobrenome Nome PaisData de nascimento (oo/MM/AA) Data admissao Abbott (oo/MM/AA) Data demissao Abbott (oo/MM/AA)

Cargo Divisao CidadeSituagao do Funcionario: Q Ativo Q Aposentado Data aposen1ad0na(oo/rum/AA) Anus ue sen/:go

Q Licenciado Q Falecido Q Contratadofiemporario

Estado civil: Q Solteiro Q Casado Q Separado Q Divorciado Q Viuvo

Sobrenome do C6n1uge Nome do Conjuge Profissio do Conjuge

Qual 6 SCU DBFGDTSSCO C0m 0 C0lab0i3d0r Abbott? (O candldato deve ser tilho dependente (ate 24 anos), em uma das categorias ilstadas abaixo)

0 Hlho/Hlha natural O EnT98d0(a) (Deve morar oom 0 coiaborador Abbott ou ser financeiramente sustentado por ele)

Q ifilho/Filha adotado(a) legalmente Q Outro (explique)

O Colaborador Abbott prove suporte flnanceiro ao estudante? Q Sim Q Nao0 outro pai/mae natural do estudante prove algum suporte financeiro ao estudante (p. ex. pensao, etc.)? Q Sim Q N50

Preencha as informagoes abaixo ("coIaborador" e voce). CNome ldade Parentesco Com 0 Colaborador Abbott

1. Colaborador:

QQ QQ- 2. Conjugez QQQ Q Q Q - ,3. Estudante:

* QiQ.Q,Q:Q-. V . deqftleguisioao oe "Bolsa de Abbott V2O0Q9QPara bolaporaooresjora,oos,i$UA eHPorf0fiiico . j

Renda FamiliarTodas as informacies tinanceiras DEVEM ser preenchidas com a moeda currente local. Nao utilize valores em dolares a nio ser queesta seja a moeda currente em sue pais.

1. Moeda corrente utilizada para as informacees abaixo (p.ex.. Euros, Beals, etc ). 12. Renda anual total bruta (2007) do colaborador Abbott 23. Se voce e aposentado, informe a pensio ou outros proventos 34. Renda anual total bruta (2007) do outro pai/mae natural 45. Renda anual total bruta (2007) do padrasto/madrasta casado(a) com colaborador Abbott 5

6. Renda anual total bruta (2007) do padrasto/madrasta casado(a) com o outro pal/mee natural 6

7. Renda anual total bruta (2007) do(a) viuvo(a) do colaborador Abbott 7Renda bruta e a renda total de todas as fontes, incluindo, mas sem se limitar a, salario, benus, incentives, antes de qualquer deducio/desconto.

Llstar outros dependentes que resldem na mesma casa e que sejam hnancelramente sustentados pelo colaborador: (Nao incluir os nomes listados na secao anterior)

Nome ldade Parentesco com o colaborador Abbott

I- P-*fn Y * 4- *- "* fr sw-r s 5* "1 * * *Z* *"*""-f f- * a * " Y* ** *G* H 1 D W* Q - "*" "**" *- P Qt

InformaQ6es Do EstudanteSobrenome Nome Nome domeio (se homew

Pais Data de nascimento (DD/MM/AA) Numero Clara Abbott de ldentiflcagao do Estudante

ESf8d0 Civil (Marque Huenas Um) C) Solteiro C) Casado Q Divorciado C) Viuvo C) Separado

Qual o nlvel educacional de sua mae?

Q Nivel medloincompleto Q Nlvel medic completo Q Nlvel superior lncompleto Q Nivel superior completo

Qual o nivel educacional de seu pai?

Q Nlvel medlolncompleto Q Nivel medio completo Q Nivel superior incomplete Q Nivel superior completo

1. Seus pals naturals sao casados entre si? 1. Q Sim2. Voce, estudante, esta atualmente no ultimo ano do nivel medio? I 2. Q Sim

Q Sim

4. , Voce, estudante, concluiu algum curso de nivel superior em uma universidade? 4. Q Sim

3. Voce, estudante, ja concluiu o nlvel medic? 3

@Trab

Q Na-o

Q Nao

Q N50

7*.:a

91.21 l Informagao Da Universidade

Nome completo da universidade que o estudante deseja cursar Local do campus (crdade)(Nome complete otlcral)

Custo Anual Total Estimado

Preencher os valores em moeda local do seu pals (e nio na moeda do pais onde 0 J GE. - . . . - * -- A oestudante Ira estudar, se for o caso). Nao utlllze valores em dolares, a nao ser que Q3. V, .E * Westa seja a moeda corrente eu seu pals.

Gustos da universidade

Moeda corrente utilizada para preencher asll1f0l*l"l18Q58S ab8iX0 (p ex. Euros, Pesos, Rea1s,etc.)2

Custo anual total estimado com mensalidades:

Mensalidade: Taxa paga para poder frequentara universidade (aulas/cursos). E tipicamente maiorque a taxa de matricula. Alguns palses oferecembolsas de isencao de mensalldades.

Custo anual total estimado com matrlcula:

Matricula: Taxaassociada a custos ad minlstrativos

Para efetuar o ingresso do estudante na universidade.Tlpicamente e menor que a mensalldade.

Custo anual total estimado com livros:

Custo anual total estimado com aulas de laboratorio

Custo anual total estimado com materials"

Custo anual total estimado com outras despesas:

Despesa (descrever): "

DSSDBSB (descrever).

Subtotal (Somar linhas 2-7b):

- - Outras-despesas: - A -H1 Custo anual total estimado com coaching/tuton"a:

2 Custo anual total estimado moradia/alimentacao"

3 Custo anual total estimado com transporte:

Data prevlsta de conclusao do 1" curso universltarlo (oo/MM/AA) Pais da universidade

KVBB de ESTUGO (Admlnlstracio, Cpmumcacao, Hnancas, etc.)

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" - roffkrfulifiordbeffeivtiiiriqrceleisaaiessaws#slow11HeirTlrlmwe@0l9,P@fa4@C9l@6@ia,if@t%@7?5rt#.iriigfvhb P@ri@tt1Br6bl*fi1titlrltfifriviilcrafleiabbor com

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A apresentacao de" recibos para estes :tens.1 sera obrigatriria no futuro

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CheckhstSua solicitacao somente sera considerada se voce apresentar a seguinte documentacao junto ao seu fom1ul" "

Cl 1. Documento oficiai sobre os custos da universidade que 0 estudante pretende cursas no ano seguinte, excluidormitorio e alimentaqao, transporte, e coaching/tutoria. Favor providenciar 01 (um) dos seguintes docume

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ano.

ndo despesas comntos:

- Lista com os custos de cada item em papel timbrado oficiai da universidade

0 Detalhamento dos custos na forma de livro/folder da universidade (em papel ou cdpia impressa extraida do web site da universidade)

0 Boleto bancario /fatura da universidade

- Recibos do ano anterior (se o estudante estiver freqiientando a mesma universidade que no ano anterior)

Cl 2. Conirmacao de que o estudante esta matriculado em institulqao de ensino medio. Favor providenciar 01 (um) dos seguintes documentos:0 Historico escoiar atualizado

0 Documento oficiai de freqtiencia no ensino medio, como carta em papel timbrado da escola ou caderneta de identificacao.G3. 1. . . . . 1. - .. 1.Coplas dos mformes de rendimentos do colaborador Abbott (mclulndo salarlo, pensao, negocros proprlos, etc.)

El 4. Copias dos informes de rendimentos de todos as outras partes que provem sustento financeiro ao estudante. Para os que nao tem meiosde fornecer um informe de rendimentos, favor preencher e assinar um Certificado de Henda Nao-comprada, que esta disponivel com seurepresentante local da Fundacao Clara Abbott

El 5. Ftecibos de pagamentos do ano escoiar anterior. Este item se aplica apenas aos estudantes que receberam bolsas de estudos da Fundacan Clara Abbott no ano anterior. Um formulario adicional deve estar mcluido a este se voce trver que apresentar tais recibos (Se voce jafomeceu estes recibos como parte dos documentos de custos-dafuniversidade solicitados aeima, favor desconsiderar).

A

C) (Obngatono)testo que as informagoes contidas neste formulario estao com letas e corretas Ao assinar este formulari dou ermissao a Fund "F Cl

fag

q p . o, p aqao araAbbott a fazer todos os questionamentos necessarios para verificar a acuracldade das informacoes aqui prestadas. Ao assinar meu nome abaixo,estou concedendo a Fundacao Clara Abbott permissao para contatar a universidade do estudante para qualquer informagao adicional sobre omesmo. Eu tenho conhecimento de que meus dados pessoais serao enviados a Fundagao nos Estados Unidos, e que os Estados Unidos podemnao possuir lens de proteqao a privacidade na mesma extensao que as de meu pals. No entanto, a Fundacao tomara medidas sensatas paraproteger minha privacidade. " " 4A Fundagao Clara Abbott nao tolerara fraude, engodo ou ocultagao de informagao neste formulario. Se a Fundagao Clara Abbott concluir que

- houve alguma das ocorrencias anteriores, podera negar qualquer solicitagao atual ou pendente, e podera nao mais prover nenhuma assistenclano futuro. Para os colaboradores Abbott, qualquer um destes comportamentos, considerados violagao no Codigo de Conduta Comercial, estarao

*su-jeitos as penalidades previstas neste Codigo. m I D* " M x h - 4As informagoes fornecidas neste formulario serao mantidas em sigilo pela Fundacao Clara Abbott, exceto quando houver requerimento legalpara divulga-las. A Fundagao Clara Abbott podera negar qualquer solicitacao de assistencia, por ser esta uma competencia tlnlca e exclusiva daFundacao. " iAssinatura do Estudante Data Assinatura do Colaborador F Data(Colaborador pode assinar pelo estudante) (0brigat6no) - * x. I V

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Informacion Numero de ldentlficacion personal (UPI) de ocho digitos

D (Sr no conoce su numero vaya al Departamento de Recursos Humanos)

Apellido del Empleado de Abbott Nombre del Empleado Pais del Empleado

Fecha de naclmiento (DD/lvlM/AA) Fecha de Empleo (oo/MM/AA) Termlnacion de Empleo (oo/MM/AA)

Titulo del Puesto del Empleado Division del Empleado Lugar de trabajo del empleado (Ciudad)

Codigo de Situacion del Empleado: Q Activo Q Jubilado Fecha de )ubuaci6n Arms de Servicio

Q Empleado en lncapacidad Prolongada Q Fallecido Q Empleado por contrato/temporal

Estado Civil del Empleado: Q Soltero(a) Q Casado(a) Q Legalmente Separado(a) Q Divorciado(a) Q Viudo(a)

Apellido del Conyuge del Empleado Nombre del Conyuge del Empleado Titulo del Puesto del Conyuge

LCUQI &S"SLl l*8l&Clf)n COFI Bl Empl8ad0 G6 Abbott? (Note que el sollcltante bene que ser un hljo o dependlente (24 aflos de edad o manor), en una de las categoriasllstadasa contlnuacion.

O Hij0(a) natural C) Hij3S"(rO(a) (Tlene que vivir con, o ser sustentado primordlalmente por el empleado de Abbott)

Q Legalmente adoptado(a) Q Otro (explique)

El empleadofdeaAbbott,.Lbrindagalgdn tipo.de-sustento economico al estudiante?

EI otro padre natural, ,gbrinda algun tipo de sustento economico al estudiante?

Complete Ia infonnacion a continuacion (empleado seria usted mismo).Nombre Edad1. Empleado

2. Conyugez

QSi QNoQSi QNo

Relacion con el Empleado de Abbott

3. Estudiante

i F114.,-.1.,-,-1 "I:-"lg: :I ,-: *,Ir.. .f I. - f "- -""- 5 * 3"" - I-j, t .1-j 3111:,--E-It N., . .., , ,V I , ,-. .9 , . r- - - . -,. -1 -1.-,g-9,. -f .5 Q M, . I* 1 9. .Sollcimfi del.P.roQrama deliecas d.e.Cl.ara Abb.QtL2.0UQ.nara.EmuIe@d0s nmesilientes en .IOS EStad0S..Umd0S. 0 Euer10..RIc0. . t. ..hum//clara.al1bon.co.m*, X--,Vg ,-,,,,,-, - -. . .. . -., ,-, L1.--. ,.,..4. 1,. ., ,. - e -.,.#. -.$33,-F.-.y . uf-2. :?".".e.-hge-.:-,--.,,*-, [email protected]."-:.j..,.- ...x .,,,.:-:.,,. J., .J ,-. ....,"..,,1.-:--.,1 -,,.:.2,e,".: r :.- . ., 9-. - .. - ,,,"-*--.-.:if..-*..-,.,- * -.g ,.

information De ingreso FamiliarToda informacion financiera tiene que incluirse en la moneda del pais donde el empleado de Abbott recibe su salario. No incluyacantidades en dolares de los Estados Unidos a menos que esta sea la moneda local de su pais.

1. lncluya el tipo de moneda utilizado para completar las preguntas a continuacidn (Por ejemplo: Euros, Pesos, etc.) 1.

2. Total de ingreso bruto anual para el aio 2007 6 2008 del empleado de Abbott 2.3. Si es jubilado de Abbott, incluya la pension u otro dinero utilizado para sustento 3.4 Total de ingreso bmto anual para el aio 2007 6 2008 del otro padre natural 4.5. Total del ingreso bruto anual para el aio 2007 6 2008 del padrastro/madrastra casado(a) con el empleado(a) de Abbott 5.

6. Total de ingreso bruto anual para el aio 2007 6 2008 del padrastro/madrastra casado(a) con el otro padre natural 6.

7. Total de ingreso bmto anual para el aio 2007 6 2008 de el/la vludo(a) del Empleado de Abbott 7.

El lngreso bmto es el total de ingresos de todos los recursos incluyendo, pero no limitado a, bonos, pago por lncentivos, antes de deducclones.

lncluya otros dependientes que vivan en el hogar de, y son sustentados por, el empleado: (No incluya los nomhres inoluidos en Ia secci6n anterior)

Nombre Edad Relaci6n con el Empleado de Abbott

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Informacicin Del EstudianteaApellido del"E-studiante Nombre del Estudiante "lnicial

Pais del Estudiante Fecha de Nacimlento del (DD/MM/AA) Numero de ldentiflcacidn de Clara Abbott del Estudlante

ESKHUO Civil del ESlUdiH0l6 (Marque Ufwl" C) Soltero(a) C Casado(a) O Dlvorciado(a) Q Viudo(a) C Legalmente Separado(a)

g,Cuz-il es el nivel mas alto de educaci6n que reclbi6 su madre7

Q Algo de educaci6n Q Algo de educaci6n Q Diploma de escuela secundaria Q Grado pos-secundariosecundaria pos-secundaria secundaria (4 aios de estudios unrversitarios)

g,Cual es el nivel mas alto de educaci6n que recibi6 su padre?

--- Q AQ Algo de egupacidnu - Q Algo de educaci6n Q Diploma de escuela secundaria. .--Q Grado poszsecundario, - .-, .- . .secundaria pos-secundaria secundaria (4 aios de estudios unlversitarios)

1. g,Estan los padres naturales del estudiante casados entre si? 1. "Q Si Q No2. g,Se encuentra usted, el estudiante, en su Ultimo aio de estudios secundarios? 2. Q Si Q No

3 g,Ha completado usted, el estudiante, alglin programa de educaci6n secundaria? 3. Q Si Q No

6 4 g,Se gradu6 usted, el estudiante, de algtin grado pos-secundano (4 aios de estudios universitarios)? 4. Q Si Q No

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Informacion De La EscuelaNombre de Ia Escuela a Ia Cual Aslstira el Estudiante Ubicacion del Campus (Ciudad)(Este debera ser el nombre oflclal y completo de la escuela de nlvel unlversltarlo)

Fecha estimada de graduacion del primer grado universitario (oo/MM/YY) Pais de Ia Escuela

Concentracion/Area de especializacionTotal Estimado De Costos Escolares Anuales

Incluya mfom1aclon en la moneda local donde el empleado/lubllado de Abbott reclhe/recibio su salario. (No donde estudia el estudiante). No incluya dolares americanos amenos que la moneda local de su pais es el dolar americano).

Costas de la escuela

1. lndique el tipo de moneda utillzado para completar 1las preguntas a continuacion (Por Ei.Eums, Pesas,e1c.)

2. lndique el total anual estimado para matricula: 2.Pago de Matricula: costos de la educacion para asistir auna escuela (cursos/clases) Este pago usualmente es muchomayor que Ia cuota de reglstro Algunos palses proveenmatrlcula gratis a los estudiantes.

3. lndique el total estimado por cuotas de registro" 3.Cuota de registro: cuota asoclada con los-costosadministrativos para que la escuela matricule a unestudlante. Tlpicamente esta cuota es mucho menorque el pago de matricula.

4. lndique-el total estimado de cuotas anuales de llbros: 4.

5. lndique el total estimado de cuotas anuales de laboratorlos: 5.

6. lndique el total estimado de materiales- 6.

N 7. lndique el total estimado de otras cuotas anuales.Cuota Gncluya descnpclon)1 7a.

Cuola (Incluya descnpclon)Z 7b.

N Subtotal (Sume las lineas 2-7b): 1

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he siiiiciiilml idsclsfs Ab56ufe"m5lE51l .ri5fl&Eiale:iilEsi"&h1l6s V"e"siabasHiligl/cls"f5.slbb6nic&&1glfffj 93.13,:I--1,:-f - he...-.4-.-sa:-::. -1,-:.v.:-M.-::f.w:s:i,,*mul-:f,.vf.@r*.,.- .-:sz-.f.2:.@:-. 1:.-:-pcs. as 1 -.1-.-...-fa..-z:.." ,.s,[email protected]..:.*.:*....-. *"-. A..4,Irss.s-,- -1. r ..*-- -ss-.1-5.-f-".:s.. -- -ru -#4-.f,.a.:-.1 .*..-s-:.- .:-,- ---r..r.* ..

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Listado De CotejoSu solicitud solo sera considerada cuando incluya los siguientes documentos con su solicitud.

Cl 1. Documentacion oficial de los costos de parte de la esuela ala cual piensa asistir el estudiante el proximo aio escolar, sin incluirhospedaje (alojamiento), transportacion y/o pagos por tutorias. Por favor, incluya uno de los siguientes:

0 Costos detallados en papel carta (con membrete) oficial de la escuela

- Costos detallados en algun folleto de la escuela (papel o copia del sitio Web de la escuela)

0 Alguna factura de Ia escuela

0 Recibos de aios escolares anteriores (si el estudiante asistira ala misma escuela que el aio anterior)

Cl 2. Verificacion que es estudiante matricuiado en una institucion pos-secundaria. lncluya uno de los siguientes:0 lnforme de calificaciones mas reciente

0 Dooumento con evidencia de matricuia tal como una carta de la escuela o tarjeta de identificacion

Cl 3. Copias de la informacion de ingresos del empleado (incluyendo ingreso del empleado de Abbott, ingresos de pensiones, ingresos porempleo propio, etc.)

*Il 4. Copias de Ia informacion de ingresos de todos los demas que proveen sustento al estudiante. En el caso de aquellos que no puedenproveer aiguna veriflcacion de ingresos, por favor, completen y firmen una Certiicacidn de ingresos No Verificados ("Certification ofUndocumented lncome"), disponible a traves de su Representante de Recursos Humanos.

Q 5. P.ecibos de aios escolares anteiiores Esto" solo aplica a estudiantes que han recibido una beca de La Fundacidn el aio anterior.Se incluye un formulario adicional con su solicitud, si usted"es requerido proveer Iosrecibos. (Si usted ya suministro estos reciboscomo parte de la documentacion oicial de los costos, por favor, haga caso omiso.)

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(Requendo)A mi mejor entender, la informacion provista en esta solicitud esta completa y correcta. Al firmar esta solicitud, doy permiso a La FundacionClara Abbott (La Fundaclon) a realizar todas las investigaciones que entiendan necesanas para verifioar la exactitud de las declaraciones hechasen esta solicitud. Al firmar abajo, doy permiso a La Fundacion para que se comunique con la escuela del estudiante para solicltar cualquierinformacion adicional sobre el estudiante. Entiendo que mi informacion personal sera recibida por La Fundacion en los Estados Unidos y quepuede que los Estados Unidos no tenga leyes que protelan mi privacidad de la misma manera como las leyes de mi pais. Sin embargo, LaFundacion tomara todos los pasos razonables para proteger mi privacidad.

, La Fundacion no tolerara fraude, engaio o encubrimiento con respecto a la informacion en esta solicitud. Si La Fundacion determinase que enefecto se incurrid en dicha conducta, podria denegar cualquier solicitud -esta o solicitudes pendientes- y podria no proveer asistencia economicaen el futuro. En el caso de los empleados de Abbott, dicha conducta se considera una violacion del Codi de Conducta Em esarial (el Codi ),- - ..-.-..u....-a - , ...,----.--- --- ...---.-.,.-.-.uma -a*.-.,--..-----,s-..*-m..-.,,.wQ,a-H--.--.-Pr. -.a.-.-aa-Q9.j.V .--- -estaran sujetos a las oonsecuencias establecidas en el Codiqo.

Lainformaoion provista a La Fundacion es confldencial, excepto segun requen"do por ley. La Fundacidn podria declinar cualquier solicitud deayuda a su unica y entera discrecicin

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3 :::.THE CLARA ABBOTT FOUNDATION O

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2. Bifoga erforderllga dokument som beskrivs i steg 5 pa den har ansokningsblanketten.

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slutdatum f6r all anses som godkand. Sena ans6kningar godkanns ej.

Obsl Alla sokande som beviljas stipendium maste tlllhandahalla kvitton pa alla utbildningsavglfter lnnan ny ans6kan om framtidastipendier lamnas in. Personalavdelningens ansvariga kommer att meddela dig nar du ska sklcka in kvrtton. Kvittonas beloppmaste dverensstamma med stlpendlesumman. Om du inte skickar ln kvltton leder det till att hela den Abbott-anstalldes familj hlndrasfran att s6ka stipendier och bidrag fran Clara Abbott i framtiden

Fragor eller kommentarer? Kontakta personalavdelningens ansvariga eller ga In pa Clara Abbott Foundationswebbplats pa http://c/ara.abbott.com.

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F6deIsedatum, anstalld (DD/MM/AA) Anstalld sedan (DD/MM/AA) Pensionerad sedan (DD/MM/AA)

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Statuskod,anstalld: Aktiv Pensionerad sedan (DD/MM/M) 1 aruqanst

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All tinansiell information MASTE anges i den valuta som anvands i det land dar den Abbott-anstillde far sin l6n. Ange intebeiopp i amerikanska dollar f6rutom om ditt lands lokala valuta ir amerikanska dollar.

1. Ange vilken valuta som anvands f6r att besvara fragorna nedan (t.ex euro, kronor osv.) 1.

2. Den anstieilldes arsinkomst 2007 eller 2008 f6re skatt 2.

3. Om du ar Abbott-pensionlar, ange din pension eller andra pengar som du far 3.

4. Arsinkomst 2007 eller 2008 fore skatt for foralder nr 2 4.

5. Arsinkomst 2007 eller 2008 f6re skatt for bonusfbralder som ar gift med anstialld pa Abbott 5.

6. Arsinkomst 2007 eller 2008 f6re skatt for bonusforalder som ar gift med foralder nr 2 6.

7. Arsinkomst 2007 eller 2008 fore skatt for anka/ankeman efter ansti:-illd pa Abbott 7

Bruttolonen ar den totala inkomsten fran alla killor inklusive, men inte begransat till, lon, bonus och provision, fore avdrag.

Ange ovriga personer I hushallet som ar ekonomiskt beroende av och forsorjs av den anstallde:(Andra namn an dem som angivits ovan)

Namn Alder Forhallande till anstalld pa Abbott, x /

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-I VIKTIGTILAS ANVISNINGARNA PA FORSTA SIDAN INNAN DU FYLLER I BLANKETFEN

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Studentens eftemamn Studentens fdmamn

Land

Studentens civilstind. (Mar/rera en)

Ensamstiende Gift

Vilken.i.r din mors h6gsta utblldning?Grundskola

Gymnasieexamen

Vllken ir din fars higsta utbildning?Grundskola Kurser pi eftergymnaslal nivi

1. Ar dina fiirildrar gifia med varandra?

2. Gir du just nu sista iret pi gymnasiet?

3 Har du, studenten, en examen frin ett gymnasieprogram?

Studentens fiidelsedatum (DD/MM/AA)

Frinskild Anka/inkeman Separerad

Kurser pi eflergymnasial nivi

Examen universitet/hdgskola (minst tre irs studier)

Gymnasieexamen Examen-universitet/hiigskola (minst tre irs studier)

4. Har du, studenten, en examen frin h6gskola/unlversitet (minst 3 irs studler)?

2. Ja Nej3. Ja Nej

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I LAS ANVISNINGARNA PA FCJRSTA SIDAN INNAN Du FYLLER I BLANKEWEN

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ilmnesomrade

UNGEFARLIGA KURSAVGIFTER PER AR

amerikanska dollar.

Utbildningsavgifter1. Ange vilken valuta som anvands f6r att besvara 1.

fragoma nedan (Lex. euro, kronor osv.)

2. Ange total undervlsningsavgifl per ar: 2Undervisningsavgift: En avgifi som tackerundervisningen pa utbildningen. Avgllten arvanliglvis h6gre an inskrivningsavglften.Vissa lander har inga undervisningskostnader.

ii. Ange total mskrivningsavgiftz 3.lnskrivningsavgift: En avgift som avser deadministrativa kostnadema for alt registrerasig pa utbildmngen. Avgllten arvanligtvis mycketlagre an undervlsnlngsavgllien.

4. Angetotal kostnad for kursbocker per ar. 4.

5. Ange total kostnad for tllltrade till laboratonum per ar: 5.

6. Ange total kostnad for forbrukningsmaterial per ar: 6

7. Ange total summa av andra avgifter:Avgifl (ange besknvnmg) 73

-- - 2 ---- AVgifi(angebeskrivn1ng) .- - -7b.

Beraknat datum f6r studentens forsta examen (DD/MM/M) Land

Totalt belopp (Addera rad 2-7b):

Alla andra avgifter

1. Ange beraknad total kostnad for undervisnlngsstod per ar: 1

2. Ange beraknad total kostnad for hyra och mat per ar:

Q Ange beraknad total kostnad for transporter. 3.

2

Ange beloppen i den valuta som anvands i det land dar den Abbott-anstallde/pensionaren far/fick sin l6n (INTEvalutan i det land dar utbildningen flnns). Ange inte belopp i amerikanska dollar f6rutom om ditt lands lokala valuta ar

Obsl

Du maste lamna in kvitton padessa avgifter tillsammans medframtida ansokningar.

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INNAN DU FYLLER I BLANKETTEN

Du maste bifoga foljande dokument med din ans6kan f6r att den ska behandlas.

Ofhciell dokumentation pa avgifter fran det larosate som studenten avser att studera vid nastkommande lasar ut6verlogi, transporter och undervisningsstod. Bifoga nagot av foljande:- Oficiellt brev fran larosatet dar avgiftema beskrivs- Utbildningsbroschyr som beskriver kostnaderna (papper eller kopia som skrivits ut fran larosatets webbplats)- Faktisk rakning fran larosatet- Kvitton fran tidigare lasar (om studenten studerar vid samma larosate som foregaende ar)

lntyg pa att studenten ar registrerad vid ett eftergymnasialt larosi-ite. Bifoga nagot av foljande:

- Det senaste kursbeviset med betyg- Dokument som visar att studenten ar registrerad vid utbildningen, t.ex. ett brev fran Iarosatet eller ett student-ID

Kopior av den anstalldes inkomstinformation (inkomst fran anstallning pa Abbott, pension,

inkomst franeget foretag osv.)

Kopior av inkomstlnformation for alla andra som ger studenten ekon

ska du fylla i och skriva under blanketten lntyg pa odok

Kvittonffran f"

od. Om du inte har nagot lntyg pa inkomst

rad lnkomst som finns pa personalavdelningen

e lasar. Detta galler enbart studenter som fait ett stipendium fran stiftelsen forut. Dufskalfyllafi

are en blankett och bifoga med din ansokan om du maste skicka in kvitton. (Om du redan har bifogat kvitton somav den ofticiella dokumentatronen av avgifter ovan kan du bortse fran detta.)

....

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Jag intygar pa heder och samvete att infonnationen i denna ansokan ar fullstandig och korrekt. Genom att skriva under dennaansokan tillaterjag att Clara Abbott Foundation (stiftelsen) gor allt som ar nbdvandigt for att bekrafta tillforlrtligheten f6r deninfomation som angivits i ansiikningsblanketten. Genom att skriva under denna ansokan tillaterjag att Clara Abbott Foundationkontaktar studentens larosate for att erhalla eventuell ytterligare infomation om studenten. Jag ar infbrstadd med att minapersonuppgifter skickas till stiftelsen i USA och att USA eventuellt inte har samma sekretess- och personuppgiftslagar som dem somgaller i mitt eget land. Stiftelsen kommer dock att vidta alla rimliga atgarder for att bevara uppgiftemas kontidentialitet.

Stiltelsen tolererar inte bedragliga eller falska uppglfter eller undanhallande av information i samband med denna ansokan. Omstiftelsen faststaller att falska uppgifter har lamnats kan den komma att ge avslag pa aktuell ansokan och den sokande kan mistaratten att ansbka om st6d i framtiden. F6r Abbott-anstallda raknas sadant beteende som ett brott mot Abbotts uppforandekod och detkommer att fa de foljder som galler f6r brott mot koden.

lnforrnationen som skickas till stlftelsen behandlas konfidentiellt forutom i de fall dar lagen kraver annorlunda. Stiftelsen forbehallersig ratten att envaldigt besluta om vem som far st6d och inte

Studentens underskrlft fansta"//d pa Abbott /ran sk/iva under/ studentens sta//e) Datum

Underskrift, anstalld (ob//gatons/rt) Datum

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CASP Uluslararasl Ba$vuru v.5/08

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t .hizmetiolfnallg $irket1 Abbott taraflndanidigvrali/nml$ iSe f of Ogrenoi, lisederi mezuri olfnU$ olmitt ve bitbu devir igleminin Uierinden en* az bir ylixgeomiol " . Universite ya da"meslek yiksek okulina ffolmahdlr. , kaydolmvug ya da kaydolmayl planlarpakta

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*BA$VURU TALiMATLARI

1. Bu ba$vuru formunu Adlm 1"den Adlm 4"e kadar tam olarak doldurun. Ttim sorular yanltlanmalldlr.

2. Bu ba$vuru formunda, Adlm 5"te behrtilen gerekli belgeleri tamamlaym.

3. Bu bagvuru formunda, Adlm 6"da istenen imzalarl tamamlaytn.

4. Burs basvutusu yapmaya hak kazanabllmek igin, bu bagvum formunu-vegdesieicteyrdiyetgeledgirkehnizin son bafgx/uru tarihinekadar yerel Insan Kaynaklan temsilcinize teslim edin. Geciken bagvurular degerlendirmeye almmayacaktlr.

Litfen Unutmayln: Burs almaya hak kazanan bagvuru sahiplerinin, tum okul masrattarlyla ilgili makbuzlan gelecekte tekrar bursbagvurusu yapmadan 6nce tedarik etmeleri gereklidir. Insan Kaynaklarl temsilciniz, bu makbuzlarl ne zaman teslim etmemzgerektlglni size bildirecektir. Bu makbuzlarln toplamt allnan burs miktanna denk olmalldlr. Makbuzlarln teslim edilmemesi halinde,llglli Abbott gallganlmn tim allesi gelecekteki Clara Abbott burslanndan ve yardlmlanndan yararlanma hakklm kaybedecektir.

Sorularlnlz ya da yorumlarlmz iqin yerel Insan Kaynaklarl temsllcinizle temasa geqebilir ya da Clara Abbott Vakfrmn

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62 OQIU/KIZI Uvey OQIU/KIZI (Abbott gallgan/yla blrllkte yagayan ya da onun bakmakla yl7kDmlD olduju)

Hukuken Evlat Edindlgi Oglu/Kizl Diger (aqlklaylnlz)

Abbott gallgam bu ogrenciye herhang: blr mali destek sagjllyor mu? Evet Haylr

Dicjer oz ebeveyni bu ogrenciye herhangi bir maddl destek sagjllyor mu (i$tirak nafakasl, vb )? Evet Haylr

Agagldaki bilgileri doldurunuz (gallgan sizseniz).

1. CaIl5an:

Q. Ogrenci" J

(en fazla 24 ya,5mda) gocugu olmasl gerektigmi unufmayln

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Finansat bilgiler ile ilgili tim talepler Abbott gallgantnln maaglnln Gdendigi ilkenin para birimi cinsinden girilmelidir. Egerilkenizin para birimi ABD dolan degil ise, miktarlan ABD dolan cinsinden ginneyin

1. Agagldaki sorularl yamtlamak igin kullanacaglnlz para birimini girin (Avro, Lira, vb) 1.

2. Abbott Iga lganlmn 2007 ya da 20008 ylll toplam yllllk brit geliri 2.

Ian dlger miktarl gin"n 33. Eger Abbott emeklislyseniz, emekli maa$m1zl ya da destek igin kullanl

4. Diger oz ebeveynin 2007 ya da 2008 ylll toplam yllllk bmt geliri 4.

5. Abbott Qallganl ile evli olan ivey ebeveymn toplam 2007 ya da 2008 yuh toplam yllllk brit getin"

6. Diger 62 ebeveyni ile evli olan ivey ebeveynin 2007 ya da 2008 ytll toplam yllllk brit geliri

5.

6

7. Abbott Qallganlnln dul e5inin2007 ya da 2008 yth toplam ylltlk brit geliri 7

Brit gelir, tim kaynaklardan elde edilen maag, prim ve ikramiyeter dahil, ancak bunlarta smlrh otmamak kaydlyla, her tirlikesinti Bncesi toplam gelirdir.

Callgamn hanesinde yagayan ve temel olarak gallganm bakmakla yikimli oldugu diger kigileri behrtin"(Bir 6nceki biilimde belirtilen isimleri dahil etmeyin)

Ad: Y.a$1L -Aiobott,QaIl$an1yIa.yaklnlllg derecesi

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Ogrencinin Ulkesi

f)Qrencinin Medeni Haliz (Bmni:garetleym)

Bekar Evli

Annenizin egitim durumu nedir?Liseyi bitlrme-mi$

Lise mezunu

Babanlzln egitim durumu nedir?Liseyi bitlrmemi$

Llse mezunu

6Qrencinin Soyadl , Ogrencinin Adl ikinci Adl

Ggrencinin Dogum Tarini (GG/AA/YY)

Bo5anml5 Dul

Yuksekokul mezunu

Universite mezunu (diirl yllllk)

Yuksekokul mezunu

Universite mezunu (dort yllllk)

1. 62 anne ve babamz birbirleri ile evlller mi?

2. Siz, yani iigrenci, lise egitiminizin son ylhnda mlslmz"7

3 Siz, yam 6Qrencl, lise egltiminizi tamamladlnlz ml?

4 Siz, yani ogjrenci, bir Universiteden yiiksek Ciejrenim diplomaslyla (4 yllllk) mezun oldunuz mu?

Hukuken Ayn

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(.51-Ejrencinin Tahmini Mezuniyet Tarihi (GG/AA/YY) Okulun Bulundugu Ulke

Egitim Brangl

TAHrvliNi YILLIK TOPLAM oKuL oiDERLERl

Miktan, Abbottugallganllemeklisinin maaglnr aldlgl ilkenin para birimi cinsinden girin (6Qrencinin egitim g6rdiQi ilkeninpara birimi DEGIL). Ulkenizin para birimi ABD dolan degil ise, miktarlan ABD dolan cinsinden gimeyin.

Okul Masraflan

1. Agagldaki somlarl yamtlamak igin kullanacaglmz 1.para binmini girin (Avro, Lira, vb.)

2 Tahmugi yllhk toplam okul Ucretmi girin: 2Okul Ucreti: Okula devam etmek lglnbdenen Ucret (ders alabilmek igin) BuUcret tlpik olarak kaylt ucretindendaha yuksektir. Bazl ulkeler, iigrencilereiicretsiz egitim sunmaktadlrlar.

Tahmip-i yllllk toplam kaylt ucretini gin"n: 3Kaylt Ucreti:#B1rfd@renmn1n4:kuiakaydedilmesi ile ilgili idari giderier. Buucret tipik olarak okul ucretindendaha dU$Uktur. Liitfen Unutmayln:

Bu giderlere iligkin makbuzlar4. Tahmini yllllk toplam kitap Ucretlerini girin: 4. - gelecekte sizden talep edilecektir.

5. Tahmini yllllk toplam Iaboratuvar harqlarlm girin* 5.

6. Tahmini yllllk toplam beslenme giderierini girin: 6.

7. Tahmini yllllk toplam diger gidederi girin:Gider (lutfen agrkiaym) 73.Gider (lutfen aglklayln) 7b.Alt toplam (Litfen 2-7b satlrlarlm topIayln):

Diger Tiim Ucretler

1. Tahmini yllllk toplam koqluk/danl5manIlk Ucretlerini gin"n: 1. "

2. Tahmini yllllk toplam oda ve yurt ucretlennl girin: 2

3 Tahmini yalllk toplam ulaglm ucretlerini girin: 3.

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Bagvuruda agagldaki belgeleri teslim etmemigseniz, bagvurunuz degerlendinneye almmayacaktlr.

Gelecek egitim ylllnda 6Qrencinin devam etmeyi planladagl okuldan almang oda ve yurt (barlnma), ulaglm, danl$manIlk

ve/veya kogluk Ucretleri harig okul giderleri ile llgili resmi belgeler. Liitfen agagldakllerden birini tedarik edin:- Resmi bir antetli okul kagldl Uzerinde masraf kalemleri- Okul brogiiriinde detayll $ekiIde g6steriImi5 egitim masraflarl (orijinal ya da okul web sitesinden allnml5 glktl)- Okul makbuzunun orijinali- Bir 6nceki egitim yllmln makbuzlarl (bgrenci iincekl yllkiyle aynl okula devam edlyorsa)

Ogrencinin lise sonrasl bir egitim kurumuna kaydolduguna dair belge Litfen agagrdakilerden birini tedarik edin:

- Ggrencinin en son not bilgileri (karne, transkript, vb) I- Okuldan allnan blr yazl ya da kimlik kartl gibi, kaylt olundugunu kanltlayan bir belge

Callgan gelir bilgllerinin kopyasi (Abbot gah$anm1n geliri, emekli maa5l, serbest meslek gelin", vb.)

Ogrenciye mali destek sagjlayan digjer tilm ki5iIerin gelir bllgllennln kopyalarl. Gelir kamtl saglayamayanlarm insan

Kaynaklan temsilcilerinden temin edebilecekleri BelgeIenmemi5 GelirSertl1ikasyon Formunu doldurmalan veimzalamalan gerekmektedir.

Bir 6nceki egitim yulma ait makbuzlar. Bu kogui yalnlzca Vaklftan 6nceki ecjitim yllmda da burs aIml$ 6QrenciIer igin

geqerlidir. Makbuzlarl tedank etmeniz gerekiyorsa, size ba5vum formunuzla birhkte ek bir form daha verilecektjr(Yukandaki resmi masraf belgeleri dahllinde bu makbuzlarl zaten teslim etmigseniz, bu maddeyi Iutfen goz 6niJnealmayln.)

1- -I-1Bilgilerim dahilinde, bu ba5vuruda sunulan bilgiler dogru ve eksiksizdir. Bu ba5vuruyu imzatayarak, Clara Abbott Vakffna(Vaklt) bu bagvuruda verilen tiim bilgilerin dogjrutugunu araatlrma iznini veriyomm. Agaglya imzaml atarak, Clara AbbottVakffna ogrenciyle ilgih her titrttl ek bilgiyi almak Uzere bgjrencinin okuluyla temasa gegme iznini veriyorum. tG$iseI bilgileriminABD"deki Vaklfa ulastlrllacaglnl ve ABD"deki kanunlarln, bilgilenmin gidlligini tllkemdeki kanunlar ile aynl 6IQUdekoruyamayabilecegini kabul ediyorum. Ancak, Abbott flrmasl bitgilerimin gizliligini korumak igin mitmkitn olan ttlm tedbirlerialacakttr.

Vaklf, bu ba$vuru formunda sunulan bilgiler ile ilgili herhangi bir sahtekartlga ya da bilgi saklama te$ebbUst1ne toleransgostenneyecektir. Eger Vaklf bu tL"lr bir davranl$ln gergekIe,$tiQini tespit ederse, onaylanml5 ya da bekleyen bir bagvuruyureddedeblhr ve ileride yardlm sagjlamayabilir. Abbott gaIt$anIarl iqin, bu tiir bir davramg Abbott Etlk Davranlg Kurallarlnln ihtalianlamma gelir ve bu kurallar dahilinde belirtilen sonuglarl dogjurur.

Vaklfa sunulan bilgiler, kanuni gereklilikter haricinde gizli tutulmaktadlr. Vaklf bir tinansal yardtm talebini reddetme hakklmsakll tutmaktadlr.

Ggjrencinin tmzasl (Cal/gan, ogrencinin yerine imzalayabilir) Tarih

QaIl$anln imzasl (Zorunlu) Tarih

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FormulirAplikasi Program Beasiswa Clara Abbott 2009untuk Pegawai di Iuar Amerika and Puerto Rico

THE CLARA ABBOTT FOUNDATION 5Aplikasi CASP Internasional v 5/08

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INSTRUKSI PENGISIAN PERMOHONAN/APLIKASI.

1. Lengkapi Langkah 1 sampai Langkah 4 dari formulir aplrkasi ini. Seluruh pertanyaan harus dijawab.

2. Sediakan dokumen yang dtpersyaratkan sebagaimana dlrtncikan di Langkah 5 aplrkasi ini.

3. Harus membubuhi tandatangan pada Langkah 6 aplrkasi ini.

4. Kembalikan aplrkasi berikut dokumen yang mendukung ke pen/vakrlan SDM selambatnya pada batas waktu aplikasi internalyang berafrliasi dengan kantor.Anda agar memenuhi syarat. Aplikasi yang melewati batasauaktu yang ditentukan tidakditerima.

Mohon catat Seluruh pemohon yang menerima beasiswa diharuskan agar menyediakan tanda terima pembayaran untuk seluruhbiaya sekolah sebetum mengajukan kembali permohonan beasiswa dr masa mendatang. Pen/vakilan SDM Anda akan memberitahuAnda kapan memasukkan tanda terima pembayaran tersebut. Tanda Terima tersebut harus sesuai dengan jumlah beasiswa. Jikagagal menyediakan tanda terima tersebut, maka seluruh keluarga Abbott tidak memenuhi persyaratan menerima bantuan danbeasiswa Clara Abbott

Qnanyaan atau komentar? Hubungi wakrl SDM Anda atau kunjung situs Clara Abbott Foundation. Di http://c/ara.abbott.com. J

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SILAKAN TULIS ATAU KETIK X

8 dijtf NOITIOF ldEI"1fmk8Si UNH( Pegawai (tanyakan SDMjika anda tldak tahu nomortersebut)

Nama Keluarga Pegawai Nama Depan Pegawai Negara Pegawai

Tanggal Lahir Pegawai (TGUBL/THN) TGL Pegawai Msk Ben-ma (ret./BLNm+N) TGL PEGAWAI BERHENTI BEKERJA (Tet./al.Nm-IN)

Status Pekerjaan Pegawai Divisi Pegawai Lokasi Pekerjaan Pegawai (Kota)

Kcde Status Pegawai: Aktif Pensiun TGL Penstun (TGL/BLNrrHN) * Masa Bekeqa

Status Pemikahan Pegawai: Blm Menikah Menikah Resmi Berpisah Cerai Janda

Pegawatmperpanlang smusaak-Mampu aexeqa Meninggal, Kontrak/Pegawai Sementara

Apakah orangtua kandung menyediakan dukungan Hnansial kepada mahasiswa (misalnya tunjangan anak, dll)? Ya Tidak

1 Pegawai:

2. Suami/Istri:

Nama Klg Suami/Istri Pegawai Nama-depan Suami/tstn Pegawai Status Pekerjaan Suami/tstri Pegawai

Apa Hubungan Anda dehgarl Peg awai Abb0ti? S1/akan catat bahwa pemohon hams anak tanggungan (lldak me/eb/m us/a 24 tahun), mem///Av

Anak Kandu ng Anak Tiri (Harus /1/dup dengan alau d/tanggung 0/eh pegawa/ Abbott)

Anak Angkat Resmi Lainnya (jelaskan)

Apakah pegawai Abbott menyediakan dukungan keuangan apa pun kepada murid tersebut? Ya Tldak

sa/ah sail/ sbtus hubungan dl bawah /nf

Lengkapi informasi di bawah ini (pegawai adalah Anda sendiri).

3 Mahasiswa.

Nama Usia Hubungan dgn Pegawai Abbott

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Seluruh informasi finansial HARUS dalam kurs uang di tempat pegawai dibayar. Jangan masukkan dalam dolar Amerika

1

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kecualr pka kurs uang di tempat Anda memang dalam kurs dolar Amerika.

1. Masukkan jenis kurs untuk melengkapi pertanyaan di bawah ini (mls.. Euros, Pesos, dII.). 1

2. Pendapatan kotor total Tahun 2007 atau 2008 pegawai Abbott 2.

3. Jrka Anda pensiunan Abbott, silakan masukkan pensiun atau uang Iainnya untuk membiayai 3.

4. Pendapatan kotor total Tahun 2007 atau 2008 orang tua kandung Iainnya 4.

5. Pendapatan kotor total Tahun 2007 atau 2008 orangtua tiri yang menikah dengan pegawai Abbott 5.

6. Pendapatan kotor total Tahun 2007 atau 2008 orangtua tiri menikahi orangtua kandung Iainnya 6.

7. Pendapatan kotor total Tahun 2007 atau 2008 janda/duda pegawai Abbott 7.

Pendapatan kotor dari seluruh sumber termasuk, namun tidak terbatas pada, gaji, bonus dandipotong.

Daftarkan-tanggungan Iainnya.dl dalam rumah atau sepenuhnya ditanggung pegawai:(Jangan masukkan nama yang telah disebut pada bagian sebelumnya)

Nama Usia Hubungan dengan Pegawai Abbott

bayaran insentif, sebelum

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Nama Keluarga Mahasiswa Nama Depan Mahasiswa Nama Tengah

Negara Mahasiswa Tanggal Lahir Mahasiswa (TGL/BLN/T HN)

Status Pemikahan Mahasiswa: (cek saw)

Blm Menikah Menikah Cerai Janda Berpisah Resmi

"Fngkat Tertinggi Pendidikan lbu Anda?Beberapa tahun di-SMU

DmbmaSMU

Beberapa Tahun dr Universitas


Tingkat Tertinggi Pendidikan ayah Anda??Beberapa tahun dl SMU

Dlploma SMU

Beberapa Tahun di Universitas


1. Apakah kedua orangtua kandung Anda menikah? 1. Ya

2. Apakah Anda pelajar, sekarang rm dr tahun terakhir SMU? 2. Ya

3 Apakah Anda telah menyelesaikan program SMU Anda 3. Ya

4. Apakah Anda pelajar yang telah menyelesaikan program Sarjana 4 tahun dari sebuah universitas? 4. Ya

N

Tidak

Tidak

Tidak

Tidak--& /

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"1" . .. 1 ff- sv "1 .fr . r-*T .--" *-1*-"ri 5.. A ,r-" .- 1111"* 1

Nama Lengkap Sekolah yang Akan Dimasu ki Lokasi Kampus (Kota)(Harus Nama Lengkap Resm/ Sekolah Akadem/ alau Un/ve/s/tas/)

Tanggal yang diharapkan untuk Vihsuda Negara Sekolahdengan Gelar Sarjana (TGUBLN/YY)

Jurusan

JUMLAH BIAYA SEKOLAH TOTAL TAHUNAN YANG DIPERKIRAKAN

Masukkan jumlah dalam kurs uang di tempat pegawai/pensiunan/dibayar (BUKAN di mana mahasiswa berkuliah).Jangan masukkan dalam dolar Amerika kecuali jika kurs uang di tempat Anda memang daiam kurs dolar Amerika.

Biaya Sekolah1. Masukkan Jenis Kurs melengkapi pertanyaan di bawah ini 1.

(mis. Euros, Pesos, dll)

2. Masukkan uang sekolah total setahun: "2.Uang Sekolah: Biaya untuk membayarpendidikan untuk mengikuti kuliah (mata kuliah/kelas-kelas).Biaya ini biasanya lebrh tinggi dari biaya pendaftaran.Beberapa Negara memberikan kuliah gratis.

3. Masukkan biaya total pendaftaranz 3Biaya Pendaftaran: Biaya sehubungan denganbiaya administrasi untuk masuk kuliahBiaya ini biasanya lebih rendah dari biaya kuliah .. Silakan Catat:

Harus Ada Bukti pembayaran di- kemudian hari

4. Masukkan biaya total buku untuk setahun: 4. .5. Masukkan biaya total Iaboratorium untuk setahun. 5.

6. Masukkan biaya total kebutuhan kuliah untuk setahun: 6.

7. Masukkan biaya total Iainnya untuk setahun.Biaya (jelaskan) 73.""@aya"ueTaska*n)"Z A "m -* 4** "Ti"1*"-A" H" -in M*

Subtotal (T ambahkan baris 2-7b): Biaya Iainnya

1 Masukkan biaya perkiraan total les/pelajaran tambahan setahun: 1.

2. Masukkan biaya perkiraan total tempat tinggal/kamar: 2

Q. Masukkan biaya perkiraan total transportasi: 3.

W

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. Aplikasi Anda akan dipertimbangkan jika dokumentasi berikut disertakan:

Dokumentasi resmi dan sekolah yang ingin dlmasuki pelajar untuk tahun berikut tidak termasuk kamar atau asrama

(akomodasi), transportasi, biaya les tambahan danlatau bimbingan, Sialakan sediakan satu document dari hal berikut ini:- I Daftar Biaya di atas lembaran sekolah dengan cap resmi- Biaya rinci dalam bentuk brochure sekolah (Iembaran kertas atau diprint dari situs sekolah)- Tanda pembayaran dari Sekolah yang sesungguhnya- Tanda terima dari sekolah tahun sebelumnya (jika mahasiswa bersekolah di tempat yang sama tahun

sebelumnya)

Veriflkasi bahwa mahasiswa berkuliah dl Akademi. Silakan sediakan satu dokumen dan" hal berikut ini:

- Angka Rapot pelajar yang terbaru- Dokumen bukti bahwa mahasiswa memang sedang berkuliah di sekolah tersebut, bisa dalam bentuk surat dari

sekolah atau kartu identiflkasi

Salinan informasi pendapatan pegawai(tem1asuk ga1ipegawaiAbbottQ pensiun, pemasukan swa-karya, dll.)

Salinan infom1asi pemasukan Iainnya yang masuh menanggung biaya mahasiswa/pelajar tersebut. Bagi siapa yang tidak

dapat menyediakan bukti pemasukkan, silakan bubuhi tanda tangan Anda pada formulir Sertlikasl Pemasukan tidakTerdokumentasi, disediakan oleh perwakilan-JSDM Anda.

Tanda terima dari beasiswa yang sebelumnya. Hal ini berlaku hanya bagi mahasiswa yang telah menerima beasiswa dari

Yayasan pada tahun sebelumnya Formulir tambahan dimasukkan berikut apllkasi Anda jnka Anda dnharuskanmenyediakan tanda terima. (Jika Anda telah menyediakan tanda tenma ini sebagai bagian dari dokumentasi resmibiaya-biaya di atas, mohon lewatkan.)

pl I

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Sejauhpapengetahuan s,aya,IirI1formasi dalam aplikasi ini adalah lengkap dan Ibenar. Dengan rnembubuhi tanda tangan di

bawah lm, sayaImembenIkan lIzln kepada Yayasan Clara AbIbott (The FIounIdIa@lon) untuk mengagman pertanyaan yang I Idlperiukan dems memvenikaslkan kebenaran pernyataan dl dalam apllkasl lm. Deragan mem u uh: nIama saya dl bawah ml,saya memberllgan izln kepada Yaybasan CIlara AbbIottIuntuIk menghubungl gekolah em: mempIeroIehIlnformasl tambahan Imengenal pelajar. Saya mengeru ahwa lnformasl pnbadl yang akan dl enma oleh Yayasan d1Amenka Senkat dan AmerikaSerilgat mungkln tidak memili i hukuIm periindunIgan priyasl sIaya sepefti hqkum yang berlaku di neagara saya. Namundem1klan,Yayasan akan mengambll Iangkah bljak dem: mellndungl pnvasl saya.

Yalyasan tldakI akan mentoleransi penipuan, kecurangan, atau sikap menutupiI/merahasiakan sehubungan dengan informasi dida am apllkasl gm. JIlka Yayasan menemukan adanya tmdakan tersebut, halIml akan mengIaklbatkanIpenolakan atau I

penundaan apI1kas1,dantldak akan menyednakan bantuan dl kemqdlan han. Bag: peg%awalIAbbot1, tmdakan tersebut dlanggiapgebagah pelanggaran terhadap Kode Ehk Perusahaan, dan akan dlkenakan san sl se agal yang termaktub dl dalam Kode takerusa aan.

Inforrnasi yang disediakan IYayasan akan bersifat komidensial kecuali jika ditentukan oleh hukum. Yayasan akan menolakpermlntaan bantuan sesual dengan kebqaksanaan dan peraturan yang berlaku.

Tanda Tangan Pelajar (Pegawai dapat me wak/// tanda tangan pe/a/ar) Tanggal

Tanda Tangan Pegawai (Waj/b) Tanggal

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deadline date to be considered eligible* Late applications vvill not be considered " I"fx

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X All applicants who receive ascholarnshipiiire reqiiiredntoiproxnde receipts for all schoollcosrs priolr to reapplying for future scholarships Your HumanI - N Resolirces representative will notifylyoullvvhen tso s:ubriiil"receiplls These receipts must match the scholarship amount Failure to provide receipts willl A result in the entire*Abbott family becopiiiingjprieliglblf-:V for all future*Clara Abbott scholarships and assistance *

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,W L , , .,Employee Information.f Employee"s 8-digit Unique Person identifier (UPl) number

(See Human Resources if you don*t know your number)

Abbott Employee Family Name Employee First Name Employee Country

Employee Birth Date (DD/Mivi/YY) Employee Hire Date (oo/iviivi/YY) Employee Termination Date (oo/Mivi/YY)

Employee Job Title Employee Division Employee Work Location (city)

ElTlpl0y88 Status COUBZ 0 ACtiVB O Retired Date of Retirement (DD/MM/YY) Years of Service

Q Employee on Extended Disability Q Deceased Q Contract/Temporary Employee

Employee Marital Status: Q Single Q Mariied Q Legally Separated Q Divorced Q Widowed

Employee Spouses Last Name Employee Spouse*s First Name Employee Spouse*s Job Title

What iS yOUr relationship t0 the Student? (Please note that the student must be a dependent child (age 24 or younger), in one of the categones listed below.)

0 Natural SON/ Daughter O Step-SOD/Daughter (Must live with or be pnmanly supported by the Abbott employee)

Q Legally Adoptive Son/Daughter Q Other (explain)

Does the Abbott employee provide any type of financial support to the student? Q Yes Q No

Does the other natural parent provide any type of financial support to the student (i e child suppoit, etc.)? Q Yes Q No

Complete information below (employee is yourself).


1. Employee:

2. Spouse: Q - Q 4 - Q3. Student:

.S3:.iii0ia@iS"Hi"iifPiiiti@tiffiiiiiiikati06 fdrfEh1iii5iiE*eEI6ui5ide,fihe" UIS- ij1"T- w:w,.*:.:fL-.". ...alan L ,,.-.ef.I... .I4."i?iT""-1"" 1.-e.-an-.*.i*..-Ein:-i.sa1L":i"l17-"517?*ilf.."*I5a*e?I 3" L-7:l.*..,$"f.":".Ei5 4.17.-.. . . ....-1""-*:*.il7.l . .v-F G--3$".tnFi::3eiz-2.2.-etrisrvcvifuimvif..

Family Income InformationAll requests for financial information MUST be entered in the currency of the country where the Abbott employee is being paid. Do notenter amounts in U.S. currency unless your country*s local currency is U.S. dollars.

1. Enter currency type used to complete the questions below (i.e. Euros, Pesos, etc.)

2. Total Year 2007 or 2008 gross annual income of Abbott employee

3. lf you are an Abbott retiree, please list pension or other money used for support

4. Total Year 2007 or 2008 gross annual income of other natural parent

5. Total Year 2007 or 2008 gross annual income of stepparent married to Abbott employee

6. Total Year 2007 or 2008 gross annual income of stepparent married to other natural parent

7. Total Year 2007 or 2008 gross annual income of widow/widower of Abbott employee

Gross income is total income from all sources including, but not limited to, salary, bonus and incentive pay, prior to any deductions.

List other dependents living within the household of and primarily supported by the employee: (Do not include the names listed in previous section)


Student Infonnationf l I

Student Family Name Student First Name Middle"Name

Student Country Student Date of Birth (DD/MM/YY) Students Clara Abbott ID Number

Student Marital Status (check one): Q Single Q Married Q Divorced Q Widowed Q Legally Separated

What is the highest level of education your father received?

Q Some Secondary School Q Secondary School Diploma Q Some Post-Secondary School

What is the highest level of education your mother received?

Q Some Secondary School Q Secondary School Diploma Q Some Post-Secondary School

l. Are your natural parents married to each other?

2. Are you, the student, currently in your last year of secondary/high school education?

3. Have you, the student, completed a secondary education program? Q4. Have you, the student, graduated with your first post-secondary degree (4-year degree) from a university?

ig I "http"//clara abbolt com " "4 2009 Clara Abbott Scholarship Program Applicatidiillor Employees Outside the U S aggr W G P*

Q Yes

Q Yes

Q Yes

Q Yes

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Q Post-Secondary Degree(four-year degree)

Q Post-Secondary Degree(four-year degree) - - -

QNo

QNo

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School informationFull Name of School Student Plans to Attend Campus Location (city)(This must be the complete official name of the post-secondary school)

Students Expected Date of Graduation with a Hirst Degree (oo/Mivi/YY) School Country

Subject Area

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Enter amounts in the currency of the country where the Abbott employee/retiree is/was * 1 * Wpaid (NOT where the student is studying). Do not enter amounts in U.S. currency unless (fi: Y ,f3*"if*E-it

your country*s local currency is U.S. dollars. 5 * J I. . 5* fzfiixitfrf -Q gl Y.School Costs 7 h1. Enter Currency Type used to complete the questions 1.

below 0.e. Euros, Pesos, etc ):

Estimated Total Annual School Costs /,NN/m,,,/.ffesw "

2. Enter estimated total annual tuition- 2.Tuition fee: A fee that is to pay for the actual education toattend a school (courses/classes). This fee is typically muchhigher than the registration fee. Some countries do providefree tuition to students.

-3. Enterestimated total registration fees: 3.Registration fee:A fee associated with the administrativecosts for the school to enroll a student. This fee is typicallymuch lower than the tuition fee. ($169.56 b@f@6:

4. Enter estimated total annual book fees: 4. - Receipts Wi" beA required for these- sitemszinztlleiuture.

5. Enter estimated total annual laboratory fees: 5.

6 Enter estimated total annual supply fees: 6.

7. Enter estimated annual other fees:

F86 (please describe): 73.FBS (please describe). 7b.Subtotal (Please add lines 2 - 7b):Ewfsiiiomefiees s . . -- sm so . . . ,KQ .1. Enter estimated total annual coaching/tutoring fees: 1 / I " *T - ,N 3

f 3, * l . 1 3."/. *fg.,1 ...2. Enter estimated total annual room and board" 2 30 .4 :A l " 5

lla? 1 s* ,we1edc*:C*""**:*"eH f"I I */R 559 , ,W W--v.w...If,,: ff 1 I3. Enter estimated total transportation 3 fl.L ,U .-/ *

3 11- I-.f**ii-i-,*..g:..iEg. :.55-: I- i-ylzera,--1:. .3-:.1-., -i.-t,:,:,., ,.,,k.* W5, ...$5 1- .ti I... I. ...NL-3. uf..-5 ,-ii.l7f.,,. .- V .,,

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0 Costs detailed in school brochure (paper or printed copy from school Web site)0 Actual school bill

- Receipts from prior school year (if student is attending the same school as prior year)

CI 2. Verihcation that student is enrolled in a post-secondary institution. Please provide one of the following:

- Most recent student grade report. . . . . . .Els.

EI4.

Document substantiating proof of enrollment such as a letter from school or identification card

Copies of employee income information (including Abbott employment income, pension income, self-employment income, etc.)

Copies of income information for all others that provide financial support to the student. For those who cannot provide proof of income,please complete and sign a Ceitification of Undocumented Income form, available from your Human Resources representative.

El 5. Receipts from prior scholarship year. This applies only to students who have received a scholarship from The Foundation in a prior year.An additional form is included with your application if you are required to provide receipts. (If you already provided these receipts as partof the official documentation of costs from Item #1, please disregard.)

"Tx

(eil Stgnatures (Reima)

To the best of my knowledge, the information on this application is complete and correct By signing this application, l grant permission to TheClara Abbott Foundation (The Foundation) to make all inquiries they deem necessary to verify the accuracy of the statements made on thisapplication By signing my name below I am granting The Clara Abbott Foundation permission to contact the students school for any additionalinformation on the student I understand that my personal data will be received by The Foundation in the U S and that the U S may not have lawsthat protect my privacy to the same extent as my country s laws However The Foundation will take all reasonable steps to protect my privacy

The Foundation will not tolerate fraud, deceit or concealment with regard to the information on this application lfThe Foundation determines thatany such behaviors have occurred it may deny any current or pending application, and may not provide future assistance For Abbott employees,any such behavior is considered a violation of the Abbott Code of Business Conduct (the Code), and will be subject to the consequences as set outin the Code

information provided to The Foundation is kept confidential except as required by law The Foundation may decline any request for assistance atits sole and entire discretion

@ checklistYour application will only be considered when you include the following documentation with your application

Official documentation of costs from the school the student plans to attend for the upcoming school year excluding room and board(accommodation) transportation, tutoring and/or coaching fees Please provide one of the following

itemized costs on official school letterhead

. /I

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Whtle The Clara Abbott Foundauon shares a close Cormectlon to Abbott and extsts solely for Abbott employees andretlrees, tt ts a not-for-proht orgamzanon managed and funded separately from Abbott The Foundations programs are notan Abbott benefit or entltlement lnformatton provlded to The Foundatlon ts kept conlidentlal except as requrred by law

CLARA HBBOTT FOUNDATION 36-6069632

FORM 990-PF DIVIDENDS AND INTEREST FROM SECURITIES STATEMENT 1

CAPITAL GAINS COLUMN (A)SOURCE GROSS AMOUNT DIVIDENDS AMOUNT

DIVIDEND INCOME 1,229,162.INTEREST INCOME 4,711,586. 0.0.

1,229,162.4,711,586.

TOTAL TO FM 990-PF, PART I, LN 4 5,940,748. onFORM 990-PF OTHER INCOME STATEMENT 2

(A)REVENUEDESCRIPTION PER BOOKS

(B)NET INVESTMENT INCOME

(C)ADJUSTED

NET INCOME

MISCELLANEOUS INCOME 12,451. 12,451.

TOTAL TO FORM 990-PF, PART I, LINE 11 12,451. 12,451.

FORM 990-PF LEGAL FEES STATEMENT 3

(A) (B)EXPENSES NET INVEST

DESCRIPTION PER BOOKS MENT INCOME(C) (D)

ADJUSTED CHARITABLENET INCOME PURPOSES

LEGAL EXPENSES 4,310. 0U onTO FM 990-PF, PG 1, LN 16A 4,310. 0. 0FORM 990-PF ACCOUNTING FEES STATEMENT 4

(A) (B)EXPENSES NET INVEST

DESCRIPTION PER BOOKS MENT INCOME(C) (D)

ADJUSTED CHARITABLENET INCOME PURPOSES

AUDIT FEE 34,000. 0. 0TO FORM 990-PF, PG 1, LN 16B 34,000. 0. 0

STATEMENT(S) 1 2 3 418 , , ,10060812 758432 ABBOCLA 2009.04o11 CLARA ABBOTT FOUNDATION ABBOCLA1

CLARA ABBOTT FOUNDATION 36-6069632llFORM 990-PF OTHER PROFESSIONAL FEES STATEMENT 5

(A) (B) (C) (D)EXPENSES NET INVEST- ADJUSTED CHARITABLE

DESCRIPTION PER BOOKS MENT INCOME NET INCOME PURPOSES1PORTFOLIO MANAGERS FEE 141,600. 141,600. 0.TO FORM 990-PF, PG 1, LN 16C 141,600. 141,600I ouFORM 990-PF TAXES STATEMENT 6


DESCRIPTION PER BOOKS MENT INCOME NET INCOME PURPOSESFEDERAL INCOME TAXES 4102,375.) ol OITO FORM 990-PF, PG 1, LN 18 (102,375.) O. olFORM 990-PF OTHER EXPENSES STATEMENT 7


DESCRIPTION PER BOOKS MENT INCOME NET INCOME PURPOSESCORP ADMIN SERVICE DEPT 15,125.MAINTENANCE/REARRANGEMENT 12,602.COMMUNICATION CHARGES 10,793.

SOOO0 0 0 0

, 15,125.12,502.10,793.BANK CHARGES 9,207. 9,207.

MISCELLANEOUS EXPENSE 38,905.CASP DEPT EXPENSES 618,285.DFAP DEPT EXPENSES 729,954.IFAP DEPT EXPENSES 398,080.

OOOOOQ I C C O

38,605.618,285.729,954.398,080.MARKETING DEPT EXPENSES 372,864. 372,864.IS DEPT EXPENSES 255,025.

FIN-MIS PRODUCTION &MAINTENANCE 79,197.FIXED CHARGES EXPENSE 79,985.CAFE EXPENSES 380,851.GLOBAL OUTREACH 289,319.OFFICE SUPPLIES 25,273.

OOCJOOC0 0 u 0 u

255,025.

79,197.79,786.

380,851.289,319.25,273.

TO FORM 990-PF, PG 1, LN 23 3,315,465. 0. 3,314,866.

STATEMENT(S) 5 6 719 , ,10060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

CBARA ABBOTT FOUNDATION 36-6069632iiFORM 990-PF CORPORATE STOCK STATEMENT 8

DESCRIPTION BOOK VALUEi FAIR MARKETVALUE

ABBOTT STOCK 56,410. 42,539,585.CAPITAL PRESERVATION FUND 770,177. 770,177.LEHMAN AGGREGATE 2,773,833.EAFE EQUITY 1,154,201.RUSSELL 1000 2,410,695.3,929,322.2,435,496.3,333,426.RUSSELL 2000 362. 362.NOBOX NL 44,831,663. 43,966,341.RUSSELL 1000 NL 75,232,289. 83,071,772.SMALL CAP INDEX COST 8,134,739. 8,839,062.ACWI INDEX 20,991,004. 21,406,458.

TOTAL TO FORM 990-PF, PART II, LINE 10B 156,355,373. 210,292,001.

FORM 990-PF PART VIII - LIST OF OFFICERS, DIRECTORS STATEMENT 9TRUSTEES AND FOUNDATION MANAGERS

NANCY KRAVCISIN-MCCLAIN (THRU04/09)1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

WILLIAM PREECE (THRU1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

JACK ATEN1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

CATHY BABINGTON1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

BILL CHASE1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

04/09)

EMPLOYEETITLE AND COMPEN- BEN PLAN EXPENSE

NAME AND ADDRESS AVRG HRS/WK SATION CONTRIB ACCOUNTDIRECTOR

1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

0. 0. 0.0. 0. 0.0. 0. 0.O. 0. O.0. 0. 0.

STATEMENT(S) 8 920 I10060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

CLARA ABBOTT FOUNDATION 36-6069632JAIME CONTRERAS1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

CHARLES FOLTZ1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

STAN FLOOD1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

STEPHEN FUSSELL1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

JOSE IBANEZ1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

ELAINE LEAVENWORTH1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

GREG LINDER1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

JOHN LUSSEN1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

STAFFORD O"KELLY1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

DAVE OLSON1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

TED OLSON1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

LAURA SCHUMACHER1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

MARCIA THOMAS1505 WHITE OAK DRIVEWAUKEGAN, IL 60085

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

DIRECTOR1.00

SECRETARY1.00

0. of ofof 0. 0.0. 0. 0.0. 0. O.0. 0. 0.0. 0. 0.O. 0. 0.0. 0. 0.0. 0. 0.0. 0. 0.O. 0. 0.0. 0. 0.0. 0. 0.

STATEMENT(S) 92110060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

CLARA ABBOTT FOUNDATION 36-6069632MIKE WARMUTH PRESIDENT1505 WHITE OAK DRIVE 1.00 0. 0. 0.WAUKEGAN, IL 60085

GUY WIEBKING DIRECTOR1505 WHITE OAK DRIVE 1.00 0. 0. 0.WAUKEGAN, IL 60085

GRICE WILLIAMS DIRECTOR1505 WHITE OAK DRIVE 1.00 0. 0. 0.WAUKEGAN, IL 60085

DIANE WINNARD DIRECTOR1505 WHITE OAK DRIVE 1.00 0. 0. 0.WAUKEGAN, IL 60085

HEATHER LOWE VICE PRESIDENT (THROUGH 10/09)1505 WHITE OAK DRIVE 40.00 0. 0. 0.WAUKEGAN, IL 60085

SHEILA RIVERA-FATHALLAH TREASURER1505 WHITE OAK DRIVE 40.00 0. 0. 0.WAUKEGAN, IL 60085

ABBOTT LABORATORIES * 0.00 363,872. 0. 0.*PURSUANT TO IRS ANNOUNCEMENT2001-33 0.00 0. 0. O.TOTALS INCLUDED ON 990-PF, PAGE 6, PART VIII 363,872. 0. 0.

22 STATEMENT(S) 910060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

CEARA ABBOTT FOUNDATION 36-6069632FORM 990-PF CASH DEEMED CHARITABLE EXPLANATION STATEMENT STATEMENT 10

PART X, LINE 4

PART X - LINE 4 MINIMUM INVESTMENT RETURN THE CLARA ABBOTT FOUNDATIONCHOOSES TO USE THE AMOUNT OF ADMINISTRATIVE EXPENSES ANDDISBURSEMENTS, AS SHOWN IN PART I LINE 26D OF THE RETURN, AS THEEXCLUDED CASH BALANCE AMOUNT OF THE MINIMUM INVESTMENT RETURN DUE TOTHE HIGH EXPENSES AND DISTRIBUTIONS.

l

23 STATEMENT(S) 1010060812 758432 ABBOCLA 2009.04011 CLARA ABBOTT FOUNDATION ABBOCLA1

Form 8868 * Application for Extension of Time To File an(Rev-A012009) Exempt Organization Return OMB N0-1545-1709Efgmaivixsgguuigesgviagw P File a separate application for each retum.

9 If you are tiling for an Automatic 3-Month Extension, complete only Part I and check this box II I I II I I I I I I I I I I ,I, P IE0 If you are tiling for an Additional (Not Automatic) 3-Month Extension, complete only Part ll (on page 2 of this form)Do not complete Part Il unless you have already been granted an automatic 3-month extension on a previously filed Form 8868

I Part I I ALIt0m3tiC 3-M0nth Extension Of Time. Only submit onginal (no copies needed).

A corporation required to file Form 990-T arid requesting an automatic 6-month extension - check this box and completePartlofily .. .. . ........ . .. . ... .PIIIAI/ other corporations (including 1120-C fi/ers), partnerships, REM/Cs, and trusts must use Form 7004 to request an extension of timeto H/e income tax retums.

Electronic Filing (e-tile). Generally, you can electronically file Form 8868 if you want a 3-month automatic extension of time to tile one of the retumsnoted below (6 months for a corporation required to file Fomi 9901") However, you cannot Hle Form 8868 electronically if (1) you want the additional(not automatic) 3-month extension or (2) you file Forms 990-BL, 6069, or 8870, group retums, or a composite or consolidated Fomi 990-T. Instead,you must submit the fully completed and signed page 2 (Part ll) of Fom1 8868. For more details on the electronic tiling of this fom1, visitvvwvv.irs.gov/efile and Click on e-ti/e for Chanties & Nonprofits.

Type orprint

Name of Exempt Organization Employer identification numberCLARA ABBOTT FOUNDATION 36-6069632

Slizittxor Number, street, and room or suite no. If a P O. box, see instructions."""9 Your 1 5 0 5 WHITE OAK DRIVEretum Seeinstructions City, town or post office, state, and ZIP code. For a foreign address, see instructions.

WAUKEGAN, IL 60085Check type of return to be filed (file a separate application for each retum).

lj Form 47201:1 Fomi 5227III Form 6069fl Form 8870

lj Form 990 E Form 990-T (corporation)ij Form 990-BL D Form 99OT (sec 401 (a) or 408(a) trust)lj Form 990-EZ E Form 990-T (trust other than above)I Form 9e0PF lj Form1041-A

SHEILA RIVERA-FATHALLAH I0 The books are in the care of P 1505 WHITE OAK DRIVE - WAUKEGAN, IL 60085

TelephoneNo.P 847-937-7835 FAXNo P0 If the organization does not have an ofnce or place of business in the United States, check this box I I II I I I I P lj0 If this is for a Group Return, enter the organizations four digit Group Exemption Number (GEN) . If this is for the whole group, check thisbox 5 II . lf it is for part of the group, check this box EP E and attach a list with the names and ElNs of all members the extension will cover.

1 I request an automatic 3-month (6-months for a corporation required to tile Form 990-T) extension of time untilAUGUST 1 5 , 2 0 1 0 , to tile the exempt organization retum for the organization named above The extension

is for the organization"s retum for:P lil calendar year 2 0 0 9 orP II tax year beginning , and ending

2 If this tax year is for less than 12 months, check reason" D Initial return I3 Final return lj Change in accounting penod

3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less anynonrefundable credits See instructions.

b lf this application is for Form 990-PF or 990-T, enter any refundable credits and estimatedtax payments made. lnclude any-pnor year overpayment allowed as a credit.

3ai$ 170,000.35 s 125,000.

c Balance Due. Subtract line 3b from line 3a lnclude your payment with this form, or, if required,deposit with FTD coupon or, if required, by using EFFPS (Electronic Federal Tax Payment System).See instmctions. ac $ 45,000.

Caution. If you are going to make an electronic fund withdrawal with this Form B868, see Form 8453-EO and Form 8879-EO for payment instructions.

LHA For Privacy Act and Paperwork Reduction Act Notice, see Instructions. Form 8868 (Rev. 4-2009)

92383105-28-09


Form 990,pF Return of Private Foundation - Charity Blossom

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Transcript of Form 990,pF Return of Private Foundation - Charity Blossom