1 APPLICANT INFORMATION
Full Name (First, Middle, Last) DOB GENDER
Home Address
City State ZIP Code
Primary Phone Number
Secondary Phone Number
Email for Registration
Employer
Work Phone
Hours worked per week Salary or hourly wage
Spouse/Signicant Other’s Full Name (First, Middle, Last) DOB GENDER
Spouse or Signicant Other’s Employer
Work Phone
Hours worked per week Salary or hourly wage
FINANCIAL ASSISTANCE APPLICATION
Today’s Date
I am a new applicant to the Financial Assistance Program.
I am reapplying for the Financial Assistance Program.
4 INCOME VERIFICATION INFORMATION
Please list the monthly totals for income and/or assistance received by your
household. Verication of these amounts is required. You must provide your
most recently led Form 1040s or Verication of Non-Filing (Form 4506-T).
Monthly Total $ N/A or Do Not Receive
Household Gross Income
Food Share and/or WIC
Unemployment
Child Support/Alimony
WI Shares/Childcare Subsidy
Housing Subsidy (Please list the
amount of assistance that you
receive, not the amount you pay.)
Energy Assistance
Social Security Disability
Supplemental Social Security
Social Security
OTHER
5 SIGNATURE
I afrm to the best of my knowledge that the above
information is true and complete. I agree to provide income
documentation as requested. I understand that this nancial
assistance is short term and that nancial assistance eligibility
is reassessed annually unless otherwise noted.
Signature of Financially Responsible Member Date
3 I AM APPLYING FOR
Household
Senior Two Adult (65+)
Senior Adult (65+)
Adult (30-64)
Young Adult (18-29)
Youth/Teen (8-17)
MEMBERSHIP
PROGRAMS
Child Care
Camp
Before/After School Care
Preschool/4K
Swim Lessons
Youth Sports
Other, please specify
2 OTHER PERSONS LIVING IN THIS HOUSEHOLD
(Add additional paper if necessary.)
Full Name (First, Middle, Last) GENDER
DOB Relationship
Full Name (First, Middle, Last) GENDER
DOB Relationship
Full Name (First, Middle, Last) GENDER
DOB Relationship
Full Name (First, Middle, Last) GENDER
DOB Relationship
Full Name (First, Middle, Last) GENDER
DOB Relationship
Full Name (First, Middle, Last) GENDER
DOB Relationship
Ways to request a non-ling verication from the IRS
ONLINE REQUEST
Available at www.irs.gov
Note: This is typically not available if you have never led taxes before
in prior years. If this is the case, please use the paper request
process detailed below.
TELEPHONE REQUEST
Available from the IRS by calling 1-800-908-9946
Note: This is typically not available if you have never led taxes before
in prior years. If this is the case, please use the paper request
process detailed below.
PAPER REQUEST FORM – IRS Form 4506-T
*Best option for those who have not led taxes in recent years.
Verications will be received within 5-10 days. Processing may
take longer during tax season, but the IRS will still issue non-ling
verications.
Download IRS Form 4506-T at:
https://www.irs.gov/pub/irs-pdf/f4506t.pdf
If you need additional help, please contact the Business Services Desk
at your YMCA location.
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