Financial Assistance Application Your Personal InformationYour Name* First Last Date of BirthPhoneYour Home Address* Street Address Unit / Suite Number City State Zip Code Your Email Address* Enter Email Confirm Email May we use email to communicate with you?*YesNoAre you currently employed?*YesNoEmployer's Name*Length of time with this employer? under 1 month 3-6 months over 1 year How often are you paid?*WeeklyBi-WeeklyMonthlyTwice MonthlySpouse Name* First Last PhoneDate of BirthYour Home Address* Street Address Unit / Suite Number City State Zip Code Your Email Address* Enter Email Confirm Email Are you currently employed?*YesNoEmployer's Name*Length of time with this employer? under 1 month 3-6 months over 1 year How often are you paid?*WeeklyBi-WeeklyMonthlyTwice MonthlyList of all dependents living in householdDependents*First NameMILast NameBirthday M/D/YRelationshipSchool Attending Check all that apply Salary/Wages School Loans/Grants Social Security Disability Retirement/Pension Food Assistance Cash Assistance Unemployment Child Support Adoption/Foster Care Subsidy Please check all that apply and provide supporting documentation. Documentation accepted: federal tax form 1040 that shows all dependents, also showing self-employment or IRS letter of non-filing. Use IRS form 4506-T, to receive letter of non-filing and copies of birth certificates. No originals please. Copies can made for you at the front desk of the downtown branch. Upload Your Financial DocumentsAccepted file types: pdf, doc, docx.Upload proof of income here.How will the YMCA's financial assistance benefit you and your family?Please list any circumstances you would like us to consider.The Legal StuffFee ScaleThe Jackson YMCA uses a sliding scale to determine a rate to fit your financial situation. All participants pay something towards their program. You will be contacted by email, phone, or letter with your award. Once this contact has been made you have 30 days to accept the award. To accept the award, you MUST visit the YMCA service desk and SIGN a payment agreement. Statement of ResponsibilityI hereby certify that the information supplied herein is true, accurate and complete to the best of my knowledge. I am also aware that it is my responsibility to notify the Jackson YMCA in writing of any change in information supplied in this application, such as income, address, living arrangements, or other matters which might affect my eligibility for financial assistance. I understand that failure to do so may result in immediate revocation of scholarship privileges.Date Date Format: MM slash DD slash YYYY Signature
