Financial Assistance Application The Johnston Urbandale Soccer Club wants to ensure all children are given the opportunity to participate in the sport of soccer regardless of their household income. Please register online first. During checkout, select "Payment by Check". To be considered for financial assistance, parents or guardians must register players, complete this form and provide documentation to verify income, see attachment A, on or before March 1, 2017. Applicant Information First Name Last Name Phone Email Address City State Zip Player Information List each player assistance is requested for, along with birth year. Please note that the players MUST be registered to be considered for financial assistance. Player Name Gender Birth Year Program (Circle One) 11/30/2017 1
Household Information Household Size: This the total number of persons living in your household (including both adults and children). Number of Dependents: This is the total number of dependent children you are able to claim for tax purposes. Employment Information Please provide CURRENT employment information information for you and your spouse/significant other residing in your household. Please list any additional employer information on an additional sheet(s) as necessary. Do NOT include employment information for any dependent children. Applicant s Employer Employee Name Employer Name Employer Address Employer Phone Number Position(s) Held: Please list those positions held within the last year. Length of Time with Employer Average Monthly Gross Income: Income received before deductions Spouse/Significant Other s Employer Employee Name Employer Name Employer Address Employer Phone Number 11/30/2017 2
Position(s) Held: Please list those positions held within the last year. Length of Time with Employer Average Monthly Gross Income: Income received before deductions Other Income Please list other average monthly income currently received, where applicable: Unemployment Social Security Income Worker s Compensation Child Support Other: Other Assistance/Circumstances Assistance Programs: Please provide the names federal or state programs providing aid to your household (e.g. Supplemental Nutrition Assistance Program, Medicaid, Family Investment Program, etc.) below. Special Circumstances: Please describe any other special circumstances why financial assistance is required (e.g. medical payments). 11/30/2017 3
Applicant Verification I verify the financial assistance eligibility information provided on this form is accurate to the best of my knowledge, and income verification documents provided reflect my household s total income. I understand that submittal of this application does not guarantee receipt of financial assistance, and that amount of assistance given is depended on number of applications received and level of need of those applicants. I also understand that incomplete applications and those without documentation to verify income may be returned and given no consideration. Signature Date Please mail all requested materials for financial assistance to: JUSC Financial Assistance - CONFIDENTIAL P.O. Box 31069 Johnston, IA 50131 11/30/2017 4
Attachment A. Income Verification Documents Please staple documentation to verify your household s gross income to the back of this application. Please black out Social Security Numbers listed on documentation. Preferred documentation is a copy of the IRS Form 1040 - Individual Income Tax Return most recently filed for the applicant s household. However, other documentation may include copies of any combination of the following: 1. IRS Form W-2 - Wage and Tax Statement. Needed for each employer listed in financial assistance application. 2. IRS Form 1099 - Miscellaneous Income. If you are self-employed, you should provide copies of all 1099s for their household. 3. Most recent pay stub (i.e. earnings statement). You may provide most recent pay stub showing year to date compensation for each employer listed in financial assistance application. 4. Letter from Employer. You may provide letter from employer on business letterhead for each employer listed in financial assistance application stating the amount compensated. Requires employer verification. 5. Unemployment Statement. Available from the state unemployment office. Only applicable where an adult member of the applicant's household is drawing unemployment income. 6. Social Security Statement. Only applicable where an adult member of your household is receiving social security income. 11/30/2017 5