Fillable Financial Assistance Request Form printable pdf download

Financial Assistance Request

Financial assistance is available to registered Girl Scouts based on need and availability of funds. An application is to be

completed by parent/legal guardian for each girl in need. All information will be keep confidential. Incomplete forms will

not be considered. Each submitted Financial Assistance Request must accompany the GSUSA Membership form or

Program Registration form. Some portion of the program fee must be paid by the family. Girls may receive one financial

assistance award per Girl Scout calendar year (October 1 through September 30). The Program Department will review

applications and notify parents/guardian of any assistance award and balance due.

PART I – PURPOSE OF REQUEST

[ ] GSUSA Membership and GSH Council Service Fee - $30.00

[ ] GSH After School Hours Program (ASHP) @ $20.00 per month

ASHP School Location: ___________________________________ Total Months Requested: ____________

[ ] Program Name: ____________________________________________ Program Cost: $___________________

PART II – GIRL INFORMATION

Name: __________________________________________________________ Troop #: ______________________

Program Level: [ ] – Daisy (gr. K – 1)

[ ] – Brownie (gr. 2 – 3)

[ ] – Junior (gr. 4 – 5)

[ ] – Cadette (gr. 6 – 8)

[ ] – Senior (gr. 9 – 10)

[ ] – Ambassador (gr. 11 – 12)

PART III – PARENT/LEGAL GUARDIAN INFORMATION

Name(s): ______________________________________________________________________________________

Mailing Address: ___________________________________________ City: _________________ Zip: ___________

Home/Cell Phone: _______________________________________ Work Phone: ____________________________

PART IV – CONFIDENTIAL INFORMATION

Section A: Family Information

Girl lives with (please select all that apply): [ ] Both Parents

[ ] Single Parent

[ ] Guardian

Number of children in family (under 18 years): __________________

Ages of children in family: ______________

Section B: Financial Information

Do you receive Federal Assistance?

1. [ ] – No (Complete the Annual Gross Family Income Level, below)

Annual Gross Family Income Level: List Annual Total Gross Income of Parent(s)/Guardian(s) living in

household or assisting with support payment(s): $_______________

Proof of income is required by GSH. Please provide one (1) of the following documents: past year’s tax return with copy of

W-2, current pay stubs for one month, letter of verification from employer stating gross wages paid and frequency of pay, or

other proof as needed.

2. [ ] – Yes (A copy of your benefit letter from Welfare Agency or SNAP document is required. Please attach

your proof document to this form.)

PART V – SIGNATURE OF PARENT/LEGAL GUARDIAN

_________________________________________________________________________________________________

Print and Sign Name

Date

FOR OFFICE USE ONLY:

ASHP Financial Assistance Granted:

[ ] Yes [ ] No

Qualifying Rate of Program Contribution: ________________________ Financial Assistance Award Amount: $___________

Annual Membership Granted:

[ ] Yes [ ] No

Payment Received: Annual Membership: $_______________

Program Fee: $_____________

Award Source Code: _____________

Confirmation Letter (date sent): ___________

Authorizing Signature: ___________________________________________________________

Date: _____________

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Rev 08-2014

Financial Assistance Request Form

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