Financial Assistance Program Application Form Page 2


Financial Assistance Payment Options
If you are approved for the Financial Assistance Program at the Downtown Oakland YMCA, you may pay for your
membership in one of four ways:
1. 3 months at a time
2. 6 months at a time
3. 1 year at a time or
4. Monthly draft
Monthly membership dues are electronically drafted to a checking account, savings account or a credit card. We accept MasterCard,
Visa, Discover or American Express. Sorry, we do not take debit or pre-paid credit cards for payment plans. To use a checking or savings
account, please present a voided check or bank document with printed routing and account numbers, and the name and address of the
account holder. Quarterly, semi-annual and annual memberships can be paid by cash, check, credit or debit card.
If you’d like to pay for your membership dues by monthly draft and you do not have a bank account please consider applying for an
account with our partner One PacificCoast Bank, FSB a Community Development Financial Institution in Downtown Oakland.
For more information about opening a new account please contact:
One PacificCoast Bank
New Accounts Representative
1438 Webster Street
Oakland, CA 94612
510 550 8400 |
What kind of documents do I need to provide for Financial Assistance?
These are the 4 acceptable options for income verification. (Additional proof of dependency is required for minors under 18.)
1. A copy of your current federal tax return
If you do not file taxes, choose one of these other options:
(1040, 1040A, or 1040EZ):
2. Pay Stubs: One month’s worth of pay stubs from all current
employers, or a letter(s) on company letterhead stating your gross
A copy of your current
monthly income (gross income is your income before taxes and
federal tax return,
benefits are taken out).
signed and dated
3. Government Assistance Letter: A recent SSI or other
with Adjusted Gross
government assistance disbursement voucher or award letter
Income (1040 line 37,
showing how much monthly income you receive.
1040A line 21,
or 1040EZ line 4).
4. Full-Time Student: If you are a student, proof of current full-
time enrollment and additional proof of income.
• Please allow approximately two weeks for processing.
• You will receive a letter of approval or denial mailed to the address listed on your application.
• If you receive an approval notice, please bring the approval sheet, application, and all documents originally submitted in to the
Downtown Oakland YMCA to start or continue your Financial Assistance membership.
• If you receive a denial notice, please read all instructions carefully and resubmit your application with the missing information.
DOWNTOWN OAKLAND YMCA 2350 Broadway, Oakland CA 94612 | 510 451 9622 |


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