Financial Assistance Application Form printable pdf download

FINANCIAL ASSISTANCE APPLICATION

Confidential Application

What is the Y Cares Financial Assistance Program?

Based upon available resources, The Community YMCA is pleased to be able to provide as much assistance as possible for qualified

individuals and families for memberships and programs. Financial Aid awards are based on a review of the applicant's household

income, and extenuating circumstances. Our hope is to never turn anyone away from a program because of inability to pay the full

price. Financial assistance may not be combined with any other form of involvement or service to or for the Y.

To evaluate your needs, the YMCA requires a variety of information about your financial situation. Financial Assistance Applications will

be considered incomplete until all application items are submitted. Once the completed application package is received, it takes

approximately four weeks to review and process. If you are applying for a scholarship for a particular program, we recommend that you

submit your completed application at least 30 days before the program starts. Applications are reviewed in the order they are received.

NOTE: Please do not include originals of any documentation, as they will not be returned.

For your privacy and security, all information is kept confidentialand treated with the utmost sensitivity.

The following information (if applicable) is required for you and any adult (s) residing in the household:

m Completed Application Form

m Income from rental properties

m A copy of your most recent Income Tax Return

m If you are receiving SSI, SSD,TANF, Food Stamps, WIC

(IRS Form 1040) with copies of all supporting W-2 forms

(Women, Infant,Child),Medicaid or Medicare, please submit

m Proof of address (utility bill, copy of rental agreement,

a copy of the Award letter.

mortgage statement or bank statement)

m If you are employed, at least four weeks of current pay stubs or

m Copy of Veteran's Benefit Statement

eight weeks of pay stubs if your pay varies from week to week.

m Verification of Alimony

m If you do not receive a pay stub, a salary verification for

m Verification of Child Support

ACD1038 must be submitted or a letter from your employer.

m Disclosure of financial support from friends, family or others

m If you are a student, submit your latest Financial Aid form

(letters may be required)

and a copy of your latest schedule.

m Disclosure of pension, IRA, annuities, dividends and earned

m If you are self-employed, you must submit your latest

interest

business and personal Income Tax Return.

m Social Services Statement/Foster Child payment slip

m If you are looking for work, you must be registered with the

m Any other financial assistance received, (i.e. college aid, etc.)

State Employment Service and submit a copy of your State

m Verification of Section 8 Housing or other subsidized housing

Employment Registration card.

assistance

m If you are unemployed, you must submit your State

m Approved letter for Food Stamp assistance

Unemployment documentation.

m Disclosure of assistance of utility bills

m If you are receiving Workers' Compensation, please provide

m Any unusual expenses (i.e. medical expenses for chronically

documentation.

ill child or adult)

It is the commitment of the YMCA to assist individuals who might otherwise not be able to afford our programs and

services. Financial assistance funds are allocated from donations received through our Annual Community Support

Campaign. The Y is a not-for-profit charity serving those in need through the YCares program. Financial assistance is

available for individuals and families on a needs-based sliding scale, based on qualifications and available resources.

Through a variety of contributions and proceeds, including the Annual Community Support Campaign, foundation grants

and special events, financial assistance is available for those with demonstrated need.

YMCA LOCATIONS

Bayshore Family Success Center, Leonardo • Camp Arrowhead, Marlboro • Camp Zehnder, Wall • Child Achievement

Center, Matawan • Counseling & Social Services, Matawan & Eatontown • Family Health & Wellness Center, Red Bank • Y

Arts, Clubs and Community Outreach, Shrewsbury

Financial Assistance Application Form

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