Financial Assistance Application Form - South Sound Ymca printable pdf download

South Sound YMCA

Financial Assistance Application

THE Y IS HERE FOR YOU!

The South Sound YMCA is committed to helping people become the best they can be. We

Expiration Date: ____/____/____

strive to keep the Y accessible to everyone regardless of their ability to pay. With the

support and generosity of our donors through our Strong Kids Campaign, we assist

Date Received:

____/____/____

everyone who qualifies.

Please check the boxes for the type of assistance you are requesting

Branch:

Olympia Downtown YMCA

Membership:

Facility

Program:

Aquatics

-Being

Applicant Information:

Name: ______________________________________ _____ ____________________________________________________

First

Last

Gender

Male

Female

Date of Birth: ____/____/____

Employer: _______________________________

(please check)

Address: ___________________________________________________________ ______________ ______ _____________

City

State

Zip Code

Home Phone #: _____________________ Work Phone #: ______________________ Cell #: __________________________

E-Mail Address: ____________________________________________________

How many Adults live in your household? _____

How Many Children? _____

Are you a current YMCA member? ______

Name (First & Last)

Date of Birth

Age

Gender

Relationship

Program requesting assistance for

____/____/____

Male

Female

____/____/____

Male

Female

____/____/____

Male

Female

____/____/____

Male

Female

____/____/____

Male

Female

Gross Monthly Income (before taxes)

Monthly Expenses

Type

Monthly Amount

Type

Monthly Amount

Wage/Salary (self)

$_____________

Rent/Mortgage

$_____________

Wage/Salary (spouse/partner)

$_____________

Groceries

$_____________

Social Security

$_____________

Phone

$_____________

Food Stamps

$_____________

Utilities

$_____________

Unemployment

$_____________

Car/Transportation

$_____________

Child Support/Alimony

$_____________

Medical

$_____________

Pension/Retirement

$_____________

Other

$_____________

Other

$_____________

Other

$_____________

TOTAL INCOME

$_____________

TOTAL EXPENSES

$_____________

How much can you afford to pay monthly for the membership/program for which you are requesting assistance? $_____

Unusual Circumstances (Please Explain): ______________________________________________________________

_______________________________________________________________________________________________

With this application, please include all of the following that apply. Your application will not be processed without:

Copies of the last 2 pay stubs from all current employers for all working applicants or a copy of most recent W2 if info is still current.

Proof of public assistance if applicable (food Stamps, DSHS, Medicaid, etc.)

Social Security, Pension, or Disability Pension income statement, unemployment or school aid verification

If you have no verifiable income, please attach a statement explain how you support yourself

NOTE: if applying for Childcare assistance, all other resources such as WorkFirst or DSHS must be exhausted first before being considered for financial aid.

I affirm to the best of my knowledge that the above information is true and complete. I agree to provide income documentation as requested. I understand this financial assis-

tance is short term only. Re-determination may occur annually, bi-annually, or monthly.

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Applicant Signature

Date