Financial Assistance Program Application Form (Page 4 of 4) in pdf

MONTHLY HOUSEHOLD INCOME Combined income from all adults in household

What kind of documents do I need to provide for Financial Assistance? These are the 4 acceptable options for income verification.

If you do not file taxes, choose one of these other options:

1. A copy of your current federal tax

2. Pay Stubs: One month’s worth of pay stubs from all current employers,

return (1040, 1040A, or 1040EZ):

or a letter(s) on company letterhead stating your gross monthly income

(gross income is your income before taxes and benefits are taken out).

A copy of your current federal tax return,

3. Government Assistance Letter: A recent SSI or other government

signed and dated with Adjusted Gross Income

assistance disbursement voucher or award letter showing how much monthly

(1040 line 37, 1040A line 21, or 1040EZ line 4).

income you receive.

4. Full-Time Student: If you are a student, proof of current full-time

enrollment and additional proof of income.

If none of these apply for you, please speak to a Manager-on-Duty.

PLEASE ATTACH PHOTOCOPIES OF APPROPRIATE QUALIFYING DOCUMENTS ALONG WITH THIS APPLICATION.

MEMBERS UNDER THE AGE OF 18

IF YOU ARE APPLYING FOR MEMBERSHIP FOR SOMEONE

Documents that can be used are:

UNDER THE AGE OF 18,

• Current tax return (1040, 1040A, or 1040EZ) listing dependents

one adult must be included on this

• A copy of rental agreement that lists your child(ren)’s name

application and a proof of dependency document is required. A birth

• An official letter with your child(ren)’s name(s) and the address

certificate is not proof of dependency.

PERSONAL STATEMENT Are there any other factors we should take into consideration?

FINANCIAL ASSISTANCE EXPIRATION

I understand that, if approved, my Financial Assistance expires no more than 1 year

after sign-up. If I pay for my membership with automatic monthly payments and my

assistance expires, I understand that regular membership rates will automatically be

withdrawn from my account.

1st Adult

2nd Adult

Paying Adult*

Initials

I understand that it is my responsibility to re-apply before the deadline given.

AUTHENTICATION STATEMENT

I acknowledge by my signature below, that all of the information on this form is accurate and complete. I agree to provide additional

documentation to verify need, if requested. I am aware that on-time program payments are required to receive financial assistance

awards. I understand I am subject to the rules and regulations of the YMCA. Supporting documents will not be returned. Each application

is reviewed and approved independently. If there are changes in your income, please notify the YMCA.

Primary Adult Signature

Date

Secondary Adult Signature

Date

Paying Adult* Signature

Date

Your signature indicates that you understand the policies and procedures of the Downtown Oakland YMCA Financial Assistance program.

*If someone who is not on the membership is paying for this membership.

YMCA financial assistance is made available through donations, grants, and association earned income.

Financial Assistance Program Application Form Page 4

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