<p> Indiana County YMCA FINANCIAL ASSISTANCE INFORMATION FORM</p><p>(To be completed by parent or guardian if applicant is under 18) While we are a not-for-profit agency, we depend on participant fees to help maintain our services. We are committed to serve people regardless of their income, but we expect participants to pay a fee based on their financial ability. Based on the available financial resources of the association, YMCA membership, class or program fees will be awarded to deserving applicants.</p><p>Applicant Information</p><p>Name: ______Date: ______Gender: ______Last First</p><p>Address: ______Street Address Apartment/Unit # ______City State Zip Code Birth date ___/___/______Home Phone ______Work phone ______Marital Status ______Number in Household ______Amount applicant is able to pay towards monthly membership: $______Please Enclose</p><p>Important: Your application will not be processed until ALL income proof has been received</p><p>Check List  Most Recent 1040 (Federal tax return)  Most Recent W-2s and/or 1099s  2 most current consecutive paycheck stubs  If applicable current SSI and/or unemployment benefit verification letter  Copy of Access Card (cash assistance) $______monthly  Child support $_____ monthly</p><p> proof of ALL household income (if public assistance only, copy of Access Card)  Most Recent 1040, and copies of most recent W-2s and/or 1099s  2 most current paycheck stubs. If self-employed, current income statement.  If applicable, current SSI and/or unemployment benefit verification letter, child support statement, etc.</p><p>Additional Information</p><p>Names and birthdates of other members of household:</p><p>1.______/____/______2.______/____/______3.______/____/______4.______/____/______5.______/____/______</p><p>Type of Membership (please  one):  Youth  Student  Adult  Family  Senior</p><p>Financial assistance is needed because: ______FINANCIAL ASSISTANCE (SCHOLARSHIP) POLICY</p><p>Those not able to pay the full fee may be awarded up to 75% assistance based on their demonstrated need. ELIGIBILITY</p><p>1. Assistance will be granted on the basis of financial need. The family income guidelines used by the Indiana County YMCA will be used as initial eligibility criteria.</p><p>2. The YMCA believes a strong sense of ownership and pride is developed if the financial assistance recipient contributes to the cost of their YMCA involvement; therefore, applicants will be asked to pay a portion of the membership or program fee.</p><p>3. Financial assistance will be reviewed for eligibility for each membership or program period. Please Note</p><p>To allow adequate processing time for financial assistance for programs, the financial assistance information form must be received by the YMCA at least two (2) weeks prior to start of registration for the program session requested or anticipated membership start date. You will be notified by mail of your aid eligibility. </p><p>HOW TO APPLY</p><p>1. Applicants must fill out all standard YMCA membership or program forms. SELECTION PROCESS</p><p>Financial assistance eligibility will be determined by the Membership Office, based on a review of the information form and/or personal interview with the applicant. Within 2 to 4 weeks, eligibility will be confirmed or denied by mail. The YMCA reserves the right to refuse assistance to any applicant.</p><p>Please complete the form on the back of this page. MAIL TO:</p><p>Indiana County YMCA 60 Ben Franklin Road North Indiana, PA 15701</p><p>Attn: Financial Assistance Committee Applicant Signature: ______Date: __/__/____</p>