Personal Pricing Plan Application

Transcription

1 **Attention Applicant: Tear this front page off and keep for your records.** Personal Pricing Plan Application About The Personal Pricing Plan is a needs-based scholarship fund made available through the Strong Kids Campaign, individual and business contributions. Personal Pricing Plans provide you with a membership or program scholarship you can afford, whether you are applying as an individual or a bustling family. With your contribution This scholarship was made possible by the Duluth Y members and through contributions of people in our community who believe in the Y. Because of donations and contributions, a greater number of individuals, families, and especially youth, in our community benefit from the programs the Y have to offer. Your willingness and/or ability to pay a portion of the regular program rate will help. Notification of Approval for Personal Pricing Plan: You will receive a letter within two-three weeks of your application, notifying you whether or not you have been approved for assistance. If your application is deemed incomplete, your application will be returned to you through mail for completion. Membership Payment Options: The Personal Pricing Plan allows you to select from 3 options for payment when signing up for a membership. i. Monthly Automatic Checking, Savings or Credit Card Withdrawal-You will need to bring in a voided check, blank deposit slip or credit card to get started with this payment option. This is taken on the 25 th of each month. ii. Quarterly Payments- Payments can be made with cash, check or credit card for 3 months at a time. The first installment of this payment type will include the joining fee, prorate of the month the membership is activated, plus the upcoming three months after. These payments must be paid in full. iii. One Year-You may pay for a full year. Payments can be made with cash, check or credit card. We want to hear from you! Sharing your positive experience with us will help raise funds so that the Y may continue providing scholarships for not only you, but other individuals and families who are in need of assistance. Please consider sharing your thoughts with us through a letter, note or . ATTENTION: Organizations who are sending clients to apply for assistance Must be non-profit and include but are not limited to transitional housing, group homes and treatment programs. A letter must be sent along with the client s application, stating the following information: Acknowledgment that you are aware this individual is coming down to the YMCA to utilize the facility and/or programs Verify your organization s non-profit status by providing your tax exempt number Verification that your organization does not qualify for or receive money from the government, for recreational activities such as client use of the YMCA We also encourage you to write any other information you think would be helpful, such as why you think this person would benefit from YMCA services and verification of their income Questions? Membership and Programs Angel Hohenstein x175 ahohenstein@duluthymca.org Out of School Programs Amber Warthesen x123 awarthesen@duluthymca.org

2 STAFF ONLY: Date of Application Submitted STEP ONE: What type of scholarship are you applying for? Membership? Yes (if yes, please mark membership type below) No Adult Two-Parent Family One-Parent Family Youth Young Adult Y Program Assistance? Yes No Out of School Programs? Yes No *Out of School Programs are not to be confused with gymnastic or swimming programs. Are you a new applicant or re-applying? New Applicant Re-applying How did you hear about the scholarship? Mentor Duluth Friend Family Online Walk-in Other: STEP TWO: Names of those applying for membership/program scholarship? Applicant s Name Phone Household Address City State Zip Birthdate Address Occupation Second Adult s Name Phone Birthdate 2 nd Adult s Occupation Name Birth Date Relationship to Applicant 1. Applicant Total number of people in your household? Do you currently reside in a: I/we live independently Group Home Board and Lodge Treatment Facility

3 STEP THREE: Monthly Income Sources, Expenses, and Other Required Documents. We will need to know the total income for all household members and how you are covering your living expenses. Please be sure to be very thorough. If any documentation is not included, application will be deemed incomplete and returned to the applicant. Income Source Monthly Amount Proof of Income **Must Be Attached** Employment $ 2 most recent paycheck stubs or written statement signed by employer stating gross wages MFIP, DWP, MSA, GA $ Letter showing monthly grant award Alimony/Child Support $ Checks, printout from the child support office or bank deposits Disability, Veteran s Benefits, Workers Compensation, Social Security, RSDI and SSI $ Award letters, bank statements showing direct deposits or copy of the check(s) Unemployment Compensation $ Unemployment statement or weekly benefit computer printout or award letter Self Employment, Farm or Rental Income $ Most recent Federal Tax Return Food Support $ Documentation from County or Disbursement History Statement Monthly Expenses: Rent/Mortgage$ Utilities $ Food $ Clothing $ Phone $ Car/Transportation$ Cable TV $ Internet $ Insurance $ Alimony $ Child Support $ Child Care $ Medical $ Entertainment$ Other $ Other $ 401K, Pension or Retirement Funds $ Benefit check(s) or a statement or an award letter Housing Assistance $ Official Documentation from agency or person providing the support Total Monthly Expenses: $ Other (Include Family Help, Plasma Donation, etc.) $ Proof of other Income Total Gross Monthly Income: $ REQUIRED DOCUMENTS If you are unable to provide either of these documents, please use the space provided below to explain why these were not included with the application. Copy of most recent tax return To obtain a free transcript of your most recent income tax return, you may call Copy of most recent bank account statement Statement provided must show activity from account. Deposit slips are not considered a valid form for statement of activities.

4 STEP FOUR: Essay Tell us about YOU Please answer the following questions. We would like to know what your needs are as well as how having this scholarship at the Duluth Y will benefit you. How will having a membership or program scholarship at the Duluth Y help you? Why are you applying for scholarship assistance? (feel free to use more paper if you run out of space) $ What is the total amount that you would have the ability to pay each month for a membership? Almost done! Please continue on to the last page.

5 STEP FIVE: Application Check-list and Terms of Agreement Initial that you have read and understand the following: I understand the Y describes its Two-Parent Family as two adults with or without dependent children (under 18 or still in H.S.), living together as a family unit not roommates. The two adults in the family can be identified as the member wishes (spouse, significant other, partner, two sisters, mother/daughter, etc ) with the exception of roommates. Proof of common permanent address is required. I understand the Y describes its One-Parent Family as a household with only one adult living with dependent children (under 18 or still in high school). I have included all applicable income documents for all household members and attached them to this application. I have attached my most recent Tax Return. I have attached my most recent bank statement. I understand that if my application is deemed incomplete, it will be mailed back to me for completion. *I certify that all information in this application and all income verification statements provided are true and complete to the best of my knowledge. Any false statements, omissions on this application or failure to report changes in your income status are grounds for revocation of the financial assistance. Signature of Applicant, Parent, Guardian, or Conservator Date application was submitted Name of Caseworker/Social Worker/Counselor (if assigned) Phone # of caseworker Name of Mentor Duluth Program Advocate (if applicable) The guidelines and application are designed to treat everyone equally and fairly. Thank you for submitting your application and we look forward to serving you soon! YMCA Office Use Only Staff Name Approval Date Membership Assistance Membership Type Discount Percentage Entered into tracking Joining Fee Monthly Rate Program Assistance Discount Percentage Expiration Date Entered into tracking Entered into Daxko Notes: