Laureen Finn/paula Brown Financial Assistance Program Application Form - 2016-2017
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1
22016-17 Laureen Finn/Paula
Brown Financial Assistance
Program Application
PART II: AMOUNT REQUESTED: (List specific
(ALL INFORMATION IS CONFIDENTIAL)
$ dollar amounts)
Directions: Please complete this application and
Annual Membership Registration
$30.00
return to Finn/Brown Financial Assistance
(Approved)
Program within 10 days of receipt from service
Troop Dues
$ ____________
center. Annual membership registration is
Girl’s Guide to Girl Scouting
$ ____________
granted immediately. Applications will be
Skill-Building Badge Set
$ ____________
processed within a month of receipt. All individual
Journey Book
$ ____________
$100.00
grants are limited to
per program year.
Sash
$ ____________
Vest
$ ____________
PART I: GIRL SCOUT INFORMATION
Id Strip, Tab, Troop #s, Pins
$ ____________
Badges/Patches
$ ____________
(Please Print)
Start-Up Kit
$____________
Council Events/Activities
__________________________________
Girl’s Name
•
_______________________$____________
____________________________________
Phone #
•
_______________________$ ____________
•
_______________________$ ____________
Address____________________________________
Regional/Community /Troop Activities
•
_______________________$ ____________
______________________________________
Town_
•
______________________ $ ____________
•
_______________________$ ____________
________________________________________
Zip
PART III: FAMILY INFORMATION:
_____________________________________
Region
Annual Adjusted Gross Income $___________________
(2012 IRS Tax Return)
Troop # (if applicable)
___________________________
Number in Family: __________
_______________________________
Leader’s Name_
List circumstances/reasons for requesting financial
assistance. Use additional paper if necessary.
_____________________________________
Phone _
_________________________________________
_________________________________________
____________________________
Leader’s Address ___
_________________________________________
_________________________________
_______________________________________
Town
Please include any of the following that you may have to
support your reason for need (copy only):
_____________________________________
Zip___
•
State Social Service Agency documentation
•
Food Stamp Determination
Leader’s Email Address:
•
School Lunch Program Eligibility
__________________________________________
•
Other appropriate income verification
Program Level: Daisy____ Brownie_____ Junior _____
(unemployment, disability, etc.)
Cadette ____ Senior ____Ambassador ____
Completed by: __________________________________
Girl applicant participated in the following product sales
Date: ____________
this year: Cookie ___ Nut ___ QSP ___
Relationship to applicant: Parent/Guardian ___
Troop Leader___ Other ___
Office Use:
Amount of Grant $____________ Date App.________
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