Financial Assistance Guidelines

Size: px

Start display at page:

Download "Financial Assistance Guidelines"

Bruno James
5 years ago
Views:

Financial Assistance Guidelines The Pomona Valley YMCA provides financial assistance to all who want to participate in the YMCA programs based on eligibility and availability of funds.

1 Financial Assistance Guidelines The Pomona Valley YMCA provides financial assistance to all who want to participate in the YMCA programs based on eligibility and availability of funds. Every application is subject to the following terms: In order to be considered for Financial Assistance the following documents are required to be completed and/or provided: MINIMUM REQUIREMENTS (Must be attached to application or app will be declined) 1. Financial Assistance Agreement Form 2. Proof of Residence (copy of I.D or Driver s license or utility Bill) 3. Most Current Tax Returns-1040 Federal Tax Return Forms. Other Documents needed (if applicable) 1. Proof of Income (for all members of the family) a. Two recent and consecutive paycheck stubs b. Child Support c. Disability d. Unemployment e. Letter of action (Welfare) f. Medi-Cal g. Social Security Award Letter h. AFDC Award Letter 2. Foster Parents and Group Homes a. State License b. Copy of Child s Birth Certificate If you are applying for childcare you must also fill out a request for employment verification or training verification. Financial Assistance is awarded for the term if the program approved. (I.e. one swim lesson, one membership period) When the program or membership is completed a renewal application must be submitted at LEAST TWO WEEKS before the next program or membership period begins in order to maintain financial assistance. The YMCA of Pomona Valley will not discriminate against race, color, sex, religion, or physical condition. If minimum requirements are not submitted with application, it will not be considered for any sort of assistance.

2 Desk Staff Initials: APPLICATION INFORMATION What program/membership are you applying for? (Please check one and specify) [] Program I am able to pay [] Membership I am to pay $ 1. Applicants description of need for financial assistance. 2. Please explain why you are requesting financial aid assistance. 3. Please explain your current financial situation. Are there any special circumstances the YMCA should know about when evaluating your application? GROUP/FOSTER HOME INFORMATION (IF IN FOSTER CARE) Child state number: Name of group and foster home: State License #: Address: Phone: Name of administrator Home phone (if different from above)

3 Pomona Valley YMCA Financial Assistance Agreement Form By signing this form, I acknowledge that I am aware of the rules and policies of the Pomona Valley YMCA Financial Assistance program as listed on the reverse side of this page (Pomona Valley YMCA Financial Assistance Guidelines.) I understand that to remain eligible for the financial Assistance I have received; I must be a current YMCA member and comply with the following terms: 1. I will pay all required fees by their due date. I understand that any delinquencies in payments (i.e. late payments, returned checks) may result in termination of Financial Assistance and suspension from the corresponding program. 2. I am responsible for returning in renewal applications. Each Financial Assistance grant lasts 6 months. As Financial Assistance recipient, I am responsible for turning in my renewable application with the proper documentation at least two weeks before the beginning of the program. I understand that no Financial Assistance grants will be applied retroactively. My signing below verifies that I have read, understand, and will abide by the policies of Pomona Valley YMCA s Financial Assistance Program. Signature All information contained in this section will remain confidential and will not be used for determination in regards to financial assistance. 1. Who is the primary income producer in your household (please check) [] Self [] Self and Spouse [] Other (specify) 2. If you or your spouse are the primary income provider in your household Father s name: Living at home? [] Yes [] No Place of Employment: Work Phone: ( ) Mother s name: Living at home? [] Yes [] No Place of Employment: Work Phone: ( ) 3. Please list the gross monthly income and expenses of the primary income provider(s) (i.e. W-2, 1040 tax-form, etc.) must accompany the information below. Application will not be processed without proper documentation. Gross Monthly Income Father s Employment Mother s Employment State/Federal Aid Food Stamps Child Support/Alimony Investment Income (Rentals, property, etc.) Other Income Specify Total Monthly Income Rent Utilities Food Transportation Medical/ Dental Insurance (Auto, home, etc) Child Care Other expenses Monthly Expenses Total Monthly Expenses

4 4. Please list names and ages of the dependents that the primary income producer is supporting. Name Age Name Age 1) 5) 2) 6) 3) 7) 4) 8) RELEASE AND SIGNATURE By filling out this application and signing below, I give permission to the Pomona Valley YMCA to use the enclosed information to evaluate my eligibility for financial assistance. I declare the statements on this application and on any accompanying attachments are true and correct. I understand that the YMCA may contact those listed on this application to verify information. Applicant s signature Address: Parent Name: Project Name: 1. Number of People in household: 2. Annual household income level (from all sources): 3. Ethnic Background: Racial Background Mark X next to the category that best describes your origin. Single Categories [] American Indian/ Alaskan Native [] Asian [] Black/ African American [] Native Hawaiian/ Other Pacific Islander White Double Categories [] American Indian/ Alaskan Native AND White [] Asian and White [] Black/ African American AND White [] American Indian / Alaskan Native AND Black/ African American Ethnic Background Mark X next to the category that best describes your origin. [] Yes, Hispanic/ Latino [] No, not Hispanic/ Latino Household Information- Check one [] a female heads the household where this client resides. [] a male heads the household where this client resides. [] Other- For individuals not identified above I certify that the above information is true and accurate and the supporting documentation can be provided upon request. Applicant s signature

5 OFFICE USE ONLY Household Size Extremely Low- Income* Low- Income* Moderate- Income* Above Moderate Income* 1 [] $17,400 or less []$17,401 to $29,000 []$29,001 to $46,400 []above $46,401 2 [] $19,900 or less [] $19,901 to $33,150 []$33,151 to $53,000 []above $53,001 3 [] $22,400 or less [] $22,401 to $37,300 []$37,301 to $59,650 []above $59,651 4 [] $24,850 or less [] $24,851 to $41,400 []$41,401 to $66,250 []above $66,251 5 [] $26,850 or less [] $26,851 to $44,750 []$44,751 to $71,550 []above $71,551 6 [] $28,850 or less [] $28,851 to $48,050 []$48,051 to $76,850 []above $76,851 7 [] $30,850 or less [] $30,851 to $51,350 []$51,351 to $82,150 []above $82,151 8 [] $32,850 or less [] $32,851 to $54,650 []$54,651 to $87,450 []above $87,451 *Please see Bulletin No for comparison of CDBG and HUD terms. Census Tract Agency s Approval

Applicant Name(s): Current Address: City, State, Zip Code Home Phone #: Work Phone #: address: Nearest Relative: Phone #: Address:

Applicant Name(s): Current Address: City, State, Zip Code Home Phone #: Work Phone #: address: Nearest Relative: Phone #: Address: HIGHLAND VIEW APARTMENTS/LE SUEUR, MN LANDMARK SQUARE APARTMENTS/LONSDALE, MN MAPLE VIEW APARTMENTS/LE CENTER, MN PHONE TOLL FREE 1-877-208-0693 or 651-578-3588 Fax #: 651-578-3588 MAILING ADDRESS: 9569