Financial Assistance Eligibility Application Form - Easton Recreation Department Page 2
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2Easton Recreation Department
Financial Assistance Eligibility Application Form
Head of Household: _
_ Number of Household Members: _
_
Address: _
_
Telephone:
_(Home)
(Cell)
Instructions for applying:
1. List the first and last name of each person living in your household, related or not (such as grandparents, other
relatives, or friends). You must include yourself and all children living with you. Attach another sheet of paper if
needed.
2. Next to each person’s name, list each type of income received last month, and how often it was received. For
example, Earnings from work: List the gross income each person earned from work. This is not the same as
take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be
listed on your pay stub, or your boss can tell you. Next to the amount, write how often it was received (weekly,
every other week, twice a month, or monthly). In column two, list the amount each person got last month from
welfare, child support, and alimony. In column three, list pensions, retirement, and Social Security. In the All
Other Income column, include Worker’s Compensation, unemployment, strike benefits, Supplemental Security
Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from people who live in
your household, and ANY OTHER INCOME.
3. Check the no income box if the person does not have any income.
Total Household Gross Income—You must tell us how much and how often
2. Gross income and how often it was received
3.
Example: $100/monthly $100/twice a month $100/every other week $100/weekly
1. Name
Check
(List everyone
Earnings from work
Welfare, child support,
Pensions, retirement,
if NO
in household)
before deductions
alimony
Social Security
All Other Income
income
(Example)
Jane Smith
$200/weekly
$150/weekly
$100/monthly
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I certify that all information on this application is true and that all income is reported. I understand that Easton Recreation
Department reserves the right to ask for written proof to verify application information. I understand that I will be financially
responsible for the full amount of any program fees if it is subsequently determined that I do not meet the eligibility
guidelines. I also understand that the awarded discount can be changed at any time due to financial constraints of the
program and availability of funding.
Signature
Date
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