Building Bridges Program - Ymca Of Greater Pittsburgh Page 3
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3Income/Expense Worksheet
Please complete the entire Worksheet or it will be returned.
Please include yours and if applicable, your spouse/significant other’s income/expense information.
Monthly Income:
Monthly Expenses:
__________
$________1
$
1) Your Gross Monthly Income
) Rent/mortgage (circle one)
(Submit last 2 pay stubs)
$____________ 2) Spouse Gross Monthly Income
$___________2) Auto Loan
(Submit last 2 pay stubs)
$_____________3) Child Support
$___________3) Home Utilities (gas, water, electric)
$_____________4) Social Security or Disability
$___________4) Telephone (listed in your name)
$_____________5) Welfare (submit a copy of card)
$____________5) Child Support
$_____________6) Food Stamps
$____________6) Medical
$_____________7) Unemployment
$____________7) Child Care
$_____________8) Other (Please explain)
$____________8) Food
______________9) Other (ie: cable, extracurricular activities (Please list with the expense amount)
$_____________ Total Monthly Income (
)
$____________Total Monthly Expenses
Household
(Household)
$_____________
Total Annual Income (
)
Household
Are there any extraordinary circumstances that should be taken into consideration when reviewing this application?
If yes, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you share expenses with anyone else in your household? _____________Total number in household ________
I have included:
(Check all that apply )
Tax Form Last Two Paystubs Social Security or Disability Documentation
CCIS Application Verification
Other Income Verification _________________________________________________________________________
I verify that all of the information submitted is correct, complete and accurate. If my situation changes, I agree to notify
the YMCA within 30 days. If I submit false or inaccurate information, or fail to notify the YMCA within 30 days, I may be
terminated from the Building Bridges Financial Assistance Program.
___________________________________________________________
___________________________
Signature
Date
Building Bridges Application 2013.docx
April 10, 2013
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