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Williamsport YMCA Financial Assistance Applicationo New Applicationo Renewal Application

Please print all information . Incomplete forms will not be processed. You must include copies of your most current W-2 and/or, IRS 1040 and/or, SSI and/or, pay stubs.Date:

Name: Home Phone:

Age: Cell Phone: ___________________________

Address: Work Phone:

City: Place of Employment:

State: Zip code Email:_______________________________

Spouse/Child(ren)s Nam e(s) Age School/Employer Birth Date1234567

Application is for what type of membership or program?

___Youth (17 years of age or younger, if 18 must be enrolled in high school).___College (Must show proof of full-time college status and college I.D.)___Adult (18 years of age or older)___Family (2 adults living in a committed relationship, their dependent children under the age of

18, unless full time college student-must provide proof of full time status and showcollege I.D.)

___Single Parent Family (1 adult household, dependent child (ren) under the age of 18, unless fulltime college student-must provide proof of full time status and showcollege I.D.)

___Program:

Have you ever applied for financial assistance before at the YMCA? Yes No

Please tell us why joining the YMCA is important to you?

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To fairly determine your eligibility for assistance, your entire family [household] annual income isrequired. You must attach copies of your most current W-2 forms and/or IRS 1040 form and/or SSIdocuments, and/or pay stubs (IF YOUR CHILD(REN) RECEIVE ASSISTANCE THIS MUST BEINCLUDED AS WELL.)

Please complete your monthly income and expenses. If you share expenses, list what you areresponsible for paying. (i.e. living w/ parents or roommate). THIS MUST BE COMPLETED. IFLEFT BLANK YOUR APPLICATION WILL NOT BE PROCESSED.

INCOME EXPENSESWages, salaries and tips $ Rent/mortgage $Unemployment compensation $ Utilities $Social Security compensation $ Food $Child Support $ Clothing $Food stamps $ Phone $

401k/retirement $ Car/insurance $Alimony $ Medical $Other $ Other $

TOTAL INCOME $ TOTAL EXPENSES $

YOU WILL BE NOTIFIED BY PHONE ONCE YOUR APPLICATION HAS BEENPROCESSED. PLEASE ALLOW (30) DAYS FOR PROCESSING.

I certify that the information I have provided is true and complete to the best of my knowledge.

__________________________________________ ______________Applicant Signature Date

Office Use OnlyCompleted packetIncomplete packet Returned to be completed

* Denied Reason* Approved __ See below for Subsidy amount and fees due.Membership Type Actual fee % Subsidy Amount of Subsidy Amount Due

Program Fee % Subsidy Amount of Subsidy Amount Due