Open Doors Scholarship Application Form - Ymca Of Ithaca & Tompkins County Page 2
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2Please indicate whether you or anyone else who lives with you receives income from any of the following sources.
Proof of all income is required, as is a copy of last year’s income tax return.
Income Source
Who Receives it
How much
How often
Employment
Unemployment
Public Cash Assistance
Food Stamps
Housing Assistance Sec 8
HEAP
SSI/SSDI Benefit
Workman’s Compensation
Retirement Benefits
Veteran’s Pension/Benefits
Education Grants/Loans
Alimony/Child Support
Child Care Supplement
Other (please explain)
Monthly expenses (less assistance from other agencies):
Please explain any EXTENUATING circumstances you may be
Expense
Monthly Cost
experiencing (i.e., death of a spouse, unexpected loss of
Mortgage/Rent
employment, etc.)
Electric
Gas
Water/Sewer
Food
To process your application, we will need the following information:
Copy of most recent tax return (If you do not have a copy of your recent tax return, you may obtain one by calling the
IRS at 1-800-829-1040)
Copy of two recent pay stubs for each working person
Copy of social security or disability checks (if applicable)
Copy of recent welfare benefits, food stamps, and/or section 8 housing letter (if applicable)
Copy of unemployment benefits statement (if applicable)
If you have no income, a letter from person(s) who provide your monthly living expenses.
Documentation of any special circumstances.
If you do not provide these forms, your application process will be delayed until you can provide us with verification of
income.
I affirm to the best of my knowledge that the information I have provided is true and complete and I acknowledge that I
must provide copies of all household income sources to cover the previous month, along with a copy of last year’s income
tax return.
To submit this application save it, attach it to an email along with income verification and email to
.
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