STRENGTHENING OUR COMMUNITY Financial Assistance ... - Ymca

STRENGTHENING OUR COMMUNITYFinancial Assistance ProgramWhat is the YMCA’s financial assistance program?The YMCA’s financial assistance program provides families in need with financial support to participate in YMCAmembership and program activities. Financial assistance is available within the Y’s available resources.How is the financial assistance amount determined?• Fees will be based on the gross monthly income you provide us when you join.• You will then have 30 days to provide income documentation verifying monthly gross income.• If you do not meet the 30 day deadline rates will automatically be increased to the standard membership rate.How do I apply?1. Complete the Confidential Application on the back page and return it to your YMCA's member service staff.2. Submit copies of the following applicable documents within 30 days of joining:*Most recent year's Federal Income Tax Form (1040 Form).Two most recent (consecutive) pay check stubsSocial Security IncomeDisability IncomeChild SupportADC/food stampsUnemploymentWhat if I haven’t filed Federal Income Taxes?For a non-filer of Federal Income Tax, contact the Internal Revenue Service at 1-800-829-8374 to request a letter ofverification of non-filing status and submit it with your financial assistance application.*Include copies for all individuals contributing to household income.

CONFIDENTIAL APPLICATIONMembership %:Program %:Please submit copies of Federal Income Tax and other forms of income(1040 Form and two most recent consecutive paycheck stubs with this application)APPLICANT INFORMATIONYour NamePhoneAddress City State ZipHousehold Size: Adults ChildrenName of person(s) for whom financial assistance is being requested:1. Birthdate 4. Birthdate2. Birthdate 5. Birthdate3. Birthdate 6. BirthdateAre you or anyone listed above currently a YMCA member?If yes, at which location?Yes NoType of membership for which you are requesting financial assistance. (Please check one):Household Single Parent Household Adult Young Adult19-22Youth0-18Senior HouseholdSenior Adult62 & olderProgram(s) for which you are requesting financial assistanceHOUSEHOLD INCOME (Required to process the application)Monthly income from all adult household wages and salaries before taxes and other deductions. Adult 1 $Adult 2 $Other Income (public assistance, child support, food stamps, social security, disability, rent assistance, etc.) $Total Monthly Income $What was your household’s total gross income for last year? $CERTIFICATION OF NEEDOur financial assistance program is made possible by countless volunteers who reach out to the community and raisemoney for our Strong Kids Campaign. Please explain why you would like to be considered for financial assistance at theYMCA and what it would mean to your family. (Use additional page if needed)I certify that the above information is true and complete to the best of my knowledge. In addition, I understand that my/ourmembership privileges are subject to the same policies of a full membership. I understand that if I do not provide the requireddocumentation within 30 days of joining, my membership rates will revert to the standard monthly rates.SignedDate