Confidential Application For Financial Assistance Page 2
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1
2What is the dollar amount that you are willing to pay or have the ability to pay?
Membership: $________________ per mo.
Program: $____________ per mo.
Child Care: $____________ per mo.
What benefits do you see in having this financial assistance to join the YMCA as a member or
participant?:
_________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Why are you applying for financial assistance?:
________________________________________________________________________
____________________________________________________________________________________________________________________________________________
NOTICE TO APPLICANTS
ITEMIZED INCOME
It is the policy of the YMCA of Greater St Louis to provide
services for any person who desires to participate and
Wages, salaries, tips
$
understands the benefits of the YMCA, regardless of
Unemployment Compensation
$
their ability to pay the standard membership or program
fees. Those not able to pay the full fee may be awarded
$
Social Security compensation
assistance, based on their demonstrated need. Funds
for financial assistance have been made available
Child Support
$
through generous contributions. Both subjective and
$
State subsidized funding
objective criteria are factored into assistance decisions.
The YMCA believes that ownership and pride are best
401K/retirement funds
$
developed when recipients of financial assistance
contribute to the cost of their YMCA involvement. Thus,
$
Alimony
all eligible recipients will be asked to pay a portion
of the membership/program fees. DFS recipients
$
Other:
will be responsible for payment of balance of fees not
$
TOTAL INCOME*
0
covered through DFS. To maintain eligibility of financial
assistance, the recipient must reapply by the expiration
*Please explain any extenuating circumstances
on their scholarship assistance letter.
Total household income must be verified at each renewal. Proof of income must be furnished by: (1)
LATEST FEDERAL TAX RETURN with W2’s attached (if applicable) and/or (2) If tax return has not been filed,
LETTER FROM GOVERNMENT AGENCY FORM 1722 must be provided. The scholarship cannot be processed
without the income verification.
Applications must be completed in full and are processed in the order they are received. Notification will
be mailed to you as to what you quality for within 2 weeks or receiving the application. Upon completing this
application and signing it, I certify that the information supplied therein is true, accurate and complete to
the best of my knowledge and have read, understand and agree with the YMCA Financial Assistance policies.
Falsification of any information for consideration of financial assistance will result in
the YMCA to immediately revoke any granted assistance.
Applicant Signature: ___________________________________________________________________ Date: __________________________
Appraisal conducted by: ____________________________________________________________ Date: ___________________________
Comments: _______________________________________________________________________________________________________________
Amount of assistance granted: $_______________________________________________
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