Financial Assistance Application Your Personal Information First Name Last Name Date of Birth Phone Your Email Address Enter Email Enter Email Confirm Email Your Home Address Street Address Unit / Suite Number City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code May we use email to communicate with you? Yes No Are you currently employed? Yes No Length of time with this employer? under 1 month 3-6 months over 1 year How often are you paid? Weekly Bi-Weekly Monthly Twice Monthly Spouse First Name Spouse Last Name Phone Date of Birth Are you currently employed? Yes No Length of time with this employer? under 1 month 3-6 months over 1 year How often are you paid? Weekly Bi-Weekly Monthly Twice Monthly List of all dependents living in household Dependents Re-order First Name MI Last Name Birthday M/D/Y Relationship School Attending Weight Operations First Name MI Last Name Birthday M/D/Y Relationship School Attending Item weight Add more items more items Check all that apply Salary/Wages School Loans/Grants Social Security Disability Retirement/Pension Food Assistance Cash Assistance Unemployment Child Support Adoption/Foster Care Subsidy Please check all that apply and provide supporting documentation. Documentation accepted: federal tax form 1040 that shows all dependents, also showing self-employment or IRS letter of non-filing. Use IRS form 4506-T, to receive letter of non-filing and copies of birth certificates. No originals please. Copies can made for you at the front desk of the downtown branch Upload Your Financial Documents Upload proof of income here. One file only.10 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. How will the YMCA's financial assistance benefit you and your family? Please list any circumstances you would like us to consider. The Legal Stuff Fee Scale The Jackson YMCA uses a sliding scale to determine a rate to fit your financial situation. All participants pay something towards their program. You will be contacted by email, phone, or letter with your award. Once this contact has been made you have 30 days to accept the award. To accept the award, you MUST visit the YMCA service desk and SIGN a payment agreement. Statement of Responsibility I hereby certify that the information supplied herein is true, accurate and complete to the best of my knowledge. I am also aware that it is my responsibility to notify the Jackson YMCA in writing of any change in information supplied in this application, such as income, address, living arrangements, or other matters which might affect my eligibility for financial assistance. I understand that failure to do so may result in immediate revocation of scholarship privileges. Date Signature Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.