Scholarships are awarded based on income, number of household members and the

availability of YMCA funds raised in our Annual Campaign.

Two months of current pay stubs•

Documentation required at time of application includes:

Household income: For both working adults within the household, please provide ONE of the following:

• Tax Return (Current year required after April 15)

Non-Filing letter to submit in lieu of the tax return. You will then need to provide additional proof of other income (i.e child support, food stamps.)

• Proof of government funds, such as housing, Social Security, disability, etc.

• Proof of child support payments

• Proof of all other income such as contractual work, unemployment checks, etc.

• Proof of dependency, school schedule and school ID if college student

• Copy of all Tax Return schedules if self-employed

Branch/Location: _________________________________Date: ____________________________H

ead of Household: _______________________________M

ember#: _______________________________

Name: ______________________________________________________________________________ Date of Birth: ________________________

Phone(Home): __________________________ (Work): _________________________________ (Cell): __________________________________

Address: ____________________________________________________ City: _____________________________ Zip Code: _______________

Email Address:_______________________________________________________ Place of Employment: ____________________________

Student, How many hours? _______________________________________

Name: ________________________________________________________________________________ Date of Birth: ________________________

Phone(Cell): ____________________________________________________ (Work): ______________________________________________________

Place of Employment: ________________________________________________________________________________________________________

Student, How many hours? _______________________________________

How many are in household ? _________

List all dependents, children or adults who are claimed on your tax return:

First Name Last Name Gender DOB Relationship to Applicant

1 / /

2 / /

3 / /

4 / /

5 / /

(Please list additional household members in the note section located on the reverse side.)

AD

ULT

1/P

AR

ENT

1A

DU

LT 2

/PA

REN

T 2

I certify that the above information is true and complete to the best of my knowledge. I agree to inform the YMCA of Abilene immediately of any changes in income or family size. I understand that false or incomplete information could jeopardize my financial assistance and that I must apply again every year.

_______________________________________________________________________________________________________________________________________

Applicant’s Signature

Please use the Notes field on the reverse side for further explanations, if needed.

Last Revised 1/2017

Monthly Income Chart

$ ________________ Household’s Monthly Gross Income (before deductions)

$ ________________ Monthly Child Support

$ ________________ Monthly Social Security/Disability

$ ________________ Monthly Government Assistance (housing, TANF)

$ ________________ Other Monthly Income (e.g. workers comp, unemployment, investments, add’l household member)

$ _______________ Total Monthly Household Income

Continuing Requirements to Maintain Financial Assistance:

1. Update contact information, including address, home phone number,work phone number,

and cell phone number for all guardians.

2. Maintain on going current account status for membership and child care.

3. Notification of changes in income for reconsideration of financial assistance needs.

4. If you do not re-apply at requested time your scholarship will expire.

5.

DOCUMENTATION NEEDED FOR SCHOLARSHIP APPROVAL PROCESS

OPEN DOORS SCHOLARSHIP APPLICATION

Partner Agency

6. After 2 bank draft returns your scholarship will no longer be active, you can re-apply

after 1 year from your scholarship termination date.

* If you do not file a tax return, call the IRS at (800) 829-1040 or go to www.irs.gov to download Form 4506-T and request a Verification of

Other Documentation:

Supporting My Community; Supporting the YMCA of AbileneI would like to contribute to the Annual Scholarship Campaign.

Total gift $ _______________ in Full. Donor Signature: _______________________________________________________________________

Income Verification

OFFICE USE ONLY

* If scholarship discount is different fromstandard discount amounts, please indicate in notes below.

Notes:________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

___________________________________________

Staff’s Signature

___________________________________________

Date

Scholarship Type

Joining Fee $__________________

Membership ___________________%

After School/ __________________% Summer Camp

Preschool ___________________%

Weekly Bi-Weekly Twice a Month Monthly

Pay Date __________________ Gross Pay ___________________

Pay Date __________________ Gross Pay ___________________

Pay Date __________________ Gross Pay ___________________

Pay Date __________________ Gross Pay ___________________

IRS Tax Return _____________________________________________

Other Income ______________________________________________

Total Annual Income _____________________________________

Verified by _______ (1st staff initials)

Verified by _______ (2nd staff initials)

The YMCA strives to provide programs that build healthy spirit, mind and body for ALL regardless of theability to pay. To ensure that these programs remain available “FOR ALL,” the YMCA of Abilene

has created the Open Doors Scholarship Program. This program is designed to provide financial assistance for all memberships offered to provide quality Child Care, Youth Programs, and/or Health & Wellness services.

Funding for Open Doors is made possible through the generous support of the Y Annual Campaign. Scholarships are awarded on a first-come, first-served basis and are subject to available resources. Applications for scholarships will be reviewed and awarded on an individual basis and you may be asked to pay a portion of program fees.

FOR ALLOpen Doors Scholarship Program

YMCA OF ABILENE

Monthly Fee $__________________

Current Balance __________________

Notes in System Yes No