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Financial Assistance Program Application Form - Town Of Basalt Recreation Department Page 2

INCOME CHART

Household Size

Total Gross Monthly Income

Percentage of Reduced Fee(s)

$1,600 & Below

50%

$2,000 & Below

50%

$2,400 & Below

50%

$2,800 & Below

50%

$3,200 & Below

50%

$3,600 & Below

50%

$4,000 & Below

50%

PARENT INFORMATION: (please print)

Mother’s Name: __________________________Father’s Name: ____________________________

Home Phone: (____)_______________________Home Phone: (____)________________________

Work Phone: (____)________________________Work Phone: (____)________________________

Physical Address: __________________________Physical Address: __________________________

___________________________

__________________________

Mailing Address: ___________________________Mailing Address: __________________________

CHILDREN INFORMATION: (please print)

Name: __________________________ Age: ________________ Date of Birth: ________________

PARENT SIGNATURE AND SOCIAL SECURITY NUMBER:

I certify that all of the above information is true and correct and that all income is reported. I understand

that the Town of Basalt can and may be verifying the information on the application and that any

deliberate misrepresentation of the information may disqualify this application form consideration and

participation in this program.

Signature of parent or Adult Household Member

Social Security #

Date

Financial Assistance Program Application Form - Town Of Basalt Recreation Department Page 2