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Financial Assistance Program Application Form - Town Of Basalt Recreation Department

TOWN OF BASALT

RECREATION DEPARTMENT

FINANCIAL ASSISTANCE PROGRAM APPLICATION

INSTRUCTIONS

To apply for financial assistance for Basalt Recreation Department programs, please complete this

application, sign your name and return the application to the Recreation Department office by mail (101

Midland Ave., Basalt, CO, 81621) or by fax (970-927-1354).

QUALIFICATIONS FOR FINANCIAL ASSISTANCE

Applicants have three (3) options to qualify for financial assistance for your children to qualify for a 50%

to full reduction in registration fees for Basalt Recreation Department programs.

Options:

1. If your household is receiving Food Stamps.

2. If your household income is receiving Aid to Families with Dependent Children (AFDC).

3. If your total household income is the same or less than the amounts on the income chart (see

Income Chart below).

1. FAMILIES RECEIVING FOOD STAMPS:

Does household receive Food Stamps? Yes______ No______

If yes, please include Food Stamp Case Number: ______________________

NOTE: Copies of materials to support this information must be attached.

2. FAMILIES RECEIVING AID TO FAMILIES WITH DEPENDENT CHILDREN

Does household receive Aid to Families with Dependent Children (AFDC)? Yes______ No______

If yes, please include AFDC Case Number: _________________________

NOTE: Copies of materials to support this information must be attached.

3. HOUSEHOLD GROSS MONTHLY INCOME:

NOTE: copies of current Income Tax Returns and Current pay stub from all employers or, if self

employed, financial statement for the last six (6) months must be attached to support the following

information!

Names of Household Members

List Total Gross Monthly Incomes

(before deductions)

Total: $

Child Support Received: $____________________________

Financial Assistance Program Application Form - Town Of Basalt Recreation Department