FINANICAL ASSISTANCE APPLICATION

Application Information:

First Name *

Middle Initial *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Date of Birth * +

Email address *

What type of membership are you applying for:
(Please only select one)

*

Family (2 adults and dependents under 23 living in the same household)

Adult (Age 24-59)

Senior (Age 60+)

Senior Couple (2 adults age 60+ living in same household)

Young Adult (Independent Living 18-23)

If applying for a Family or Senior Couple membership:

List all person in your household (excluding yourself)

2nd Parent/Adult First and Last Name:

Date of Birth +

Dependent First and Last Name:

Date of Birth +

Dependent First and Last Name:

Date of Birth +

Dependent First and Last Name:

Date of Birth +

Dependent First and Last Name:

Date of Birth +

Dependent First and Last Name:

Date of Birth +

Total annual household income: *

Income Documentation

Please provide as many of the following forms of income documentation that apply to your household and reflect your current income.

*If you are applying for Family or Senior Couple membership, we require income documentation for both adults in the household.

Federal Taxes: Federal Tax Form(s) for the current year for all income in household

Employer Paystubs: 2 most recent paystubs

Government Assistance: DHS/Food Assistance-Full report showing awarded amount, SSI/SSDI/Pension Report- Official letter or bank statements showing awarded amount

Student Documentation: Finanical Aid Budget breakdown

Additional Documentation: Child Support-Offical letter showing awarded amount

Unemployement Benefits-Offical letter showing awaarded amount

Attach any supporting documents
(1040 IRS Tax Form, Recent Paystub, Proof of Government Assistance, etc.) *

THIS APPLICATION MUST BE RENEWED EVERY 12 MONTHS.

I certify that the above information is true and complete to the best of my knowledge, and that I do not have additional income not represented above. I agree, if necessary, to send additional information and documentation to support the above statements. I understand that flexible pricing is based on need. In the event that I or my children must cancel our participation, I will contact the YMCA immediately so that this benefit may be provided to others. I understand that if I falsify any of the above information, I will not be eligible for assistance now and/or in the future.

*

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Applications are reviewed on the 1st and 15th of each month. You will then receive a determination letter by mail or email. Please do not contact the branch to check on your application as we will get back to you as soon as possible.

Thank You!

If you'd like to tell us more; Use this space to include any additional information, extenuating circumstances or examples (major medical expenses not covered by insurance, divorce, job loss, change in income, etc.) that were not included in this application.