Scholarship Application Form - Ymca Of The Fox Cities Page 3
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3Monthly Household Income
Monthly Household Expenses
Gross Monthly Income
$__________
Mortgage/Rent
$__________
Spouse/Partner Earnings
$__________
Food
$__________
Unemployment
$__________
Utilities
$__________
Social Security Income
$__________
(Gas/Electric/etc.)
SS Insurance
$__________
Transportation
$__________
(Car loan/Gas/Insurance)
Investment Income
$__________
(Rental Property, Etc.)
Other income
$__________
Total Monthly Income
$_________
Medical Costs
$__________
Child Care
$__________
Child Support
$__________
ASSISTANCE:
Life Insurance
$__________
Family Assistance
$__________
Cell Phone
$__________
Child Care Assistance
$__________
Cable
$__________
Medical Assistance
$__________
Internet
$__________
Government Assistance
$__________
Other__________________ $__________
Housing Subsidy
$__________
Food Stamps
$__________
Do you have anyone else living in your
Tuition/Grant
$__________
household who is not listed on the previous
Maintenance/Child Support
$__________
page:
Yes
No
o
o
Foster Care Payments
$__________
Who? _____________________________
Assets:
Savings
$__________
Total Monthly Assistance
$__________
Total Monthly Expenses
$__________
Details of other income:
____________________________________________________________________________________________
____________________________________________________________________________________________
Provide details and copies of other expenses:
____________________________________________________________________________________________
____________________________________________________________________________________________
Please explain any special circumstances that you wish us to consider:
____________________________________________________________________________________________
____________________________________________________________________________________________
Are the following documents included with this application for processing?
YES
q Required: Copy of most recent tax return/W2/1099 forms OR ‘Taxes not filed’ letter from IRS
q Required: Copy of two recent payroll stubs OR Copy of unemployment check stubs
q If Applicable: Verification of any other assistance (food stamps, child support, housing assist., etc)
q If Applicable: Social Security income verification (tax return not required)
Staff Notes:
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