8/22/2019 Financial Aid Application RVR - 7 17 2013

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RIVER VALLEY REGIONAL YMCA FINANCIAL ASSISTANCE APPLICATION

NEW APPLICATION RENEWAL APPLICATION Date Application Submitted / /

STEP 1 Enter Household Information:

First / Last Name: Date of Birth: / _/ Age: Gender: M FPhone Number: E-Mail Address:

Address: APT: City: State: Zip:

Check One: Single: Married: Separated:

List names (including last names if different from applicant) and ages of everyone residing in your household:

First Name, Last Name Age DOB Gender Relationship Employment StatusMM/DD/YY i.e. spouse, son, etc i.e. working part time, student, etc

1.

2.

3.

4.

5.

/ _/

/ _/

/ _/

/ _/

/ _/

M FM FM FM FM F

(Please use an additional application OR attach another document if you need extra space for additional names.)

STEP 2 Verify current total household income and submit supporting documents:

What is the current, combined annual household income? $ please ensure supporting documents aid in verifying total income

Submit a copy of your most recent federal tax return form 1040 AND a copy ofONE of the following supporting documents:

Last two pay stubs, for all household members

Retirement income documentationSocial security or disability award letter(s)

Unemployment income verification

If a current year OR prior year federal tax return - form 1040 HAS NOT BEEN FILED please submit a copy ofALL the followingsupporting documents that are applicable for verification ofHOUSEHOLD income:

Last two pay stubs, for all household membersRetirement income documentation

Social security or disability award letter(s)

Unemployment income verificationTemporary Cash Assistance

Do you receive Child Support? YES NO If yes, what is monthly support? $_ Please provide supporting documents

Attach an optional letter stating the applicants specific need and/or hardship. Please include special circumstances (if any) in the letter.

STEP 3 Signature of Applicant: _ Date:

The information I have provided on this form is complete and correct and I agree to provide additional documentation upon request to verify need of financial

assistance. I understand that the Y provides financial assistance to the extent that resources are available and that the Y reserves the right to refuse assistance

to any applicant. I also understand that my current Y account must be in good standing prior to this application being processed.

STEP 4 CHILD CARE ONLY Specify location below, including specific school or camp site:

Camp:

Before / After School Enrichment:

Early Childhood Development:

Location listings are available

online at RVRYMCA.org or at

any Y Branch.

All applicants are required to apply for Department of Public Welfare (DPW) Child Care Subsidy Program (CCSP) vouchers and submit a copy of your

decision letter prior to our processing this application.

Submit completed application and all supporting documentation to the Y by either:

MAIL: 320 Elmira Street, Williamsport PA 17701 Attn: Financial Assistance

IN PERSON: At your local Y Branch

APPLICATION FOR: (please check any) REGIONAL LOCATION (please check o

MEMBERSHIP TYPE:

OTHER PROGRAM:

Williamsport

Eastern Lycoming

Jersey Shore

Bradford

Tioga

Child Care:

CAMPBEFORE/AFTER SCHOOL ENRICHMENT

EARLY CHILDHOOD DEVELOPMENT

http://www.ymaryland.org/http://www.ymaryland.org/http://www.ymaryland.org/