2020 FA Form YMCACW

YMCA of Columbia-Willamette

Financial Assistance Application
The YMCA is a nonprofit organization that works to strengthen the foundations of community through programs that support youth development, healthy living, and social responsibility. Thanks to the generous support of those who donate to the Y’s Community Support Campaign and our fundraising events. We believe that a strong sense of ownership and pride is developed when the recipient has contributed to the cost of their YMCA involvement; therefore, you will be asked to pay some portion of the fees.

How is the amount of financial assistance determined?
We use a sliding scale based on total household income and the number of household members. We require supporting documentation to verify household size and income, and we consider special circumstances when providing assistance.

What does the YMCA consider “Income”?
We ask that applicants list all types of income, including: Wages, Tips, Retirement, Social Security (SS), Supplemental Security Income (SSI), Disability, Unemployment, Temporary Assistance for Need Families (TANF), Child Support, Alimony, Housing Assistance, Food Stamps, etc. Please remember to count the income of anyone living in your household and contributing to household expenses such as rent, utilities, or groceries.

You can qualify in one of two ways:
1. If currently participate in either TANF or Free Lunch assistance programs you can automatically qualify for financial assistance. Please submit a copy of the current reward letter.
2. If you do not participate in one of the above government assistance programs, you can qualify based on your total household income. Please submit proof of income.
How long does my assistance last?
Financial assistance is granted for up to one calendar year from award date.

How do I apply?
Individuals need to provide all requested information on the Financial Assistance Application including a verifiable address, income, household size and expenses so financial assistance can be provided in a fair and consistent manner. All information will be kept confidential.

Please complete the entire form, sign, date and submit to your local Y. All information is confidential. Completion of this application does not guarantee approval. Your complete application will be processed within 5 to 10 business days from date received.
Please select YMCA branch/program where assistance is being applied. *
Are you applying for membership? *
Please specify program you are applying for? *
Please specify Child Care location you are applying to? *

Primary Adult
IF YOU ARE APPLYING FOR ASSISTANCE FOR SOMEONE UNDER THE AGE OF 18, one adult must be included on this application and proof of dependency document is required. A birth certificate is not proof of dependency.

Documents that can be used are:
- Current tax return (1040, 1040A, or 1040EZ) listing dependents
- A copy of rental agreement that lists your child(ren)’s name
- An official letter with your child(ren)’s name and the address listed on your financial application
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Do you receive income? *
ENTER ADDITIONAL FAMILY MEMBERS THAT ARE SUPPORTED ON TOTAL INCOME.

Secondary Adult
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Do you receive income?

Family Member | 1
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Relationship

Family Member | 2
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Relationship

Family Member | 3
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Relationship

Family Member | 4
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Relationship

Family Member | 5
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Relationship

Monthly Household Income

Combined from all adults in household
Employment *
Unemployment *
Retirement Income *
Child Support *
Alimony *
SSI/SSD *
Housing Assistance *
Food Stamps/SNAP *
Pensions/Savings/Investments *
TANF *
Student Loans *
Other Income *
Total Income *
Total number of people living on stated income? *
Are you receiving financial assistance at any other YMCA? *
If so, where?
Does your child receive Reduced or Free Lunch? *
Income Documentation
To process your application in the most efficient manner, please include ALL required documents. Incomplete applications will result in delayed processing.

Please attach appropriate qualifying documents:
1. Reduced or free lunch letter
2. Current tax return
3. Two most recent pay stubs from all working adults in household.
4. Documentation of any other assistance or income received.
Attach Income Documentation *

Cancel of

Personal Statement & Acknowledgement

Personal Statement
Are there any other factors we should take into consideration?

Financial Assistance Expiration
The YMCA reviews applications annually; failure to submit a new application will result in membership or program fees automatically moving to the full rate. If I have automatic monthly payments and my assistance expires, I understand that the full rate will automatically be withdrawn from my account. I understand it is my responsibility to reapply before the deadline given.
Signature *

Clear

Acknowledgement
I declare that the aforementioned statements, to the best of my knowledge and belief, are true and correct. I agree to inform the YMCA of any changes in my financial status.
Signature *

Clear
Should be Empty:

YMCA of Columbia-Willamette

Primary Adult

Monthly Household Income

Income Documentation

Personal Statement & Acknowledgement