HomeMy WebLinkAboutFinancial Assistance Application_December 2019O'Brien / YMCA Partnership
Financial Assistance Application
Membership Type: Individual Couple Household
Please note: This application requires the income of everyone in the household, including those not on the membership. We cannot accept $0 income.
Incomplete paperwork or income requirements may delay your assistance process. SNAP or Cash Assistance through the Department of Human Services is
an instant approval of 45%. Include pages 1 & 2 with application.
Adult #1
Full Name
Address
City State Zip
Date of Birth Phone
Current Status Employed Student Retired SS/Disability
Last 12 Months of Employment (Include additional employers on separate sheet)
Employer Start Date End Date
Employer Start Date End Date
Are you currently a student? Yes No If yes, class schedule & loan/grant income is required with this application.
Are you currently employed? Yes No If no, why?
Fill in each section that applies to you:
Salary $
Unemployment $
SSI/Disability $
Please attach proof of monthly gross income, last federal tax return filed with W2, and if self-employed, Schedule C tax return.
Cash Assistance $
Pension/Retirement $
Child Support/Alimony $
Food Stamps $
Other $
Adult #2
Full Name
Date of Birth Phone
Current Status Employed Student Retired SS/Disability
Last 12 Months of Employment (Include additional employers on separate sheet)
Employer Start Date End Date
Employer Start Date End Date
Are you currently a student? Yes No If yes, class schedule & loan/grant income is required with this application.
Are you currently employed? Yes No If no, why?
Continued on next page.
Adult #2 Continued
Fill in each section that applies to you:
Salary $
Unemployment $
SSI/Disability $
Please attach proof of monthly gross income, last federal tax return filed with W2, and if self-employed, Schedule C tax return.
Cash Assistance $
Pension/Retirement $
Child Support/Alimony $
Food Stamps $
Other $
Additional Adult(s) 18+
Residing in same household. Please attach proof of residency & income. Additional adults are required to pay a monthly add-on
fee unless they are a full-time student under 24 years old. Proof of class schedule required for students.
Name DOB M/F
Current Status Employed Student Retired SS/Disability
Name DOB M/F
Current Status Employed Student Retired SS/Disability
Dependents (0-17 years old)
Residing in same household. Need proof of filed tax returns or school records. (Include additional dependents on separate sheet)
Name DOB Age
School/Grade Child Support $ SS/Disability $
Name DOB Age
School/Grade Child Support $ SS/Disability $
Name DOB Age
School/Grade Child Support $ SS/Disability $
Please use this space to include any other factors that we should take in consideration in evaluating your request
I certify that the information I have provided is true and complete to the best of my knowledge. I agree to notify the YMCA if my financial
status should change. I understand that inaccurate and incomplete information may cause termination from the financial assistance program.
I understand that if my application is approved, my assistance will be reviews on an annual or semi-annual basis and adjusted based on my
circumstances at that time.
Signature Date
Unit #
Date Received
Staff Initials
Approved Yes No
Member ID
New Renewal
Date Processed
FA Reviewer
Renewal Date OFFICE USE ONLY