Provide a match of a 2:1 ratio (for every one dollar the participant saves, it will be matched with two dollars)

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1 Program Overview The Back On Track Matched Savings Accounts program is administered by United Way of the Bluegrass in partnership with local/regional community agencies. An Individual Development Account (IDA) is a matched savings account which encourages savings and personal financial planning to help low-income individuals and families build productive assets and self-sufficiency. IDAs provide matching funds for individuals savings into a designated account for one of three specific purposes: Home ownership Post-secondary education Small business start-up Back On Track uses two sources of funds: federal funding through the Assets for Independence program, administered by the U.S. Department of Health and Human Services and contributions from the local/regional community. These funding sources will: Provide a match of a 2:1 ratio (for every one dollar the participant saves, it will be matched with two dollars) Allow participants to save up to $2,000 which will then be matched by an additional $4,000 Once a participant is enrolled in the program, savers will qualify for matching funds by completing the following steps: Participate in the savings program for a minimum of 6 months and no more than 2 years (although a one year no-cost extension is possible). Attend at least 10 hours of free financial management training that includes such topics as improving credit, setting up a budget and savings schedule, and the basics of money management. Attend at least 8 hours of free training that is specific to the asset for which they are saving (e.g., how to purchase and maintain a home, how to enroll in post-secondary classes, how to start a small business). Meet or check-in once a month with a Back On Track case manager. Make a monthly IDA deposit of at least $30. Purchase a designated asset by August 31, Program Overview

2 Candidate Eligibility Participation in the Back On Track program is limited to individuals or households with incomes at the time of enrollment of approximately 150 percent and not more than 200 percent of the official Federal Poverty Level. Anyone seeking to participate in the Back On Track program must have household incomes at the time of enrollment that fall within the annual amounts related to household size that are listed in the chart below. % Gross Yearly Income Family 25% 50% 75% 81% 100% 150% 175% 200% Size 1 $2,723 $5,445 $8,168 $8,821 $10,890 $16,335 $19,058 $21,780 2 $3,678 $7,355 $11,033 $11,915 $14,710 $22,065 $25,743 $29,420 3 $4,633 $9,265 $13,898 $15,009 $18,530 $27,795 $32,428 $37,060 4 $5,588 $11,175 $16,763 $18,104 $22,350 $33,525 $39,113 $44,700 5 $6,543 $13,085 $19,628 $21,198 $26,170 $39,255 $45,798 $52,340 6 $7,498 $14,995 $22,493 $24,292 $29,990 $44,985 $52,483 $59,980 7 $8,453 $16,905 $25,358 $27,386 $33,810 $50,715 $59,168 $67,620 8 $9,408 $18,815 $28,223 $30,480 $37,630 $56,445 $65,853 $75,260 For families with more than 8 persons add $3,820 for each additional person at 100% of poverty; $5,730 at 150%; $6,685 at 175%; and $7,640 at 200%. Criteria for Approval To qualify for the program, candidates must: 1. Be 18 years of age or older 2. Have earned income of approximately 150% and not more than 200% of the Federal Poverty Level 3. Have no more than $10,000 in assets/net worth (excluding ownership one home and one automobile) 4. Live in the nine-county United Way of the Bluegrass service area. These counties include: Anderson, Bourbon, Clark, Fayette, Jessamine, Madison, Montgomery, Scott, Woodford. No more than two eligible members per household may participate in the IDA Program. Each participant must have earned income. Welfare payments, Supplemental Security Income (SSI), Social Security Disability Income (SSDI) payments, state or federal training program stipends and Unemployment Compensation are not considered earned income. Salary and wage statements and W-2 forms are adequate documentation of income eligibility. Program Overview

3 Back on Track Participant Responsibilities As a participant in the Back on Track program, will you be able to do the following? Make monthly deposits into your account of at least $30 for a minimum of 6 months Identify an asset goal: homeownership, starting a small business, or continuing your education Meet monthly with a case manager (provided by the Back On Track program) Attended 10 hours of financial literacy class (provided by the Back On Track program) Attended 8 hours of asset-specific training (provided by the Back On Track program) Have your taxes prepared through a free Volunteer Income Tax Assistance Program Deposit a portion of your tax refund into your account If you answered yes to all of these requirements, you may be a great fit for the Back On Track program! Please fill out the enclosed application and return it to: United Way of the Bluegrass C/O Mike Burke 2480 Fortune Drive, #250 Lexington, KY Upon receiving the application, you will be contacted by either Michael Burke or Cate Mart to discuss the status of your application. Approved applicants will be asked to come in for a brief orientation session for the Back On Track program. If you have any questions about the application, please contact Michael Burke at (859) ext. 238 or Cate Mart at (859) ext You may also contact Michael by at michael.burke@uwbg.org and Cate at cate.mart@uwbg.org

4 Application Thank you for taking the time to complete this application. The information you provide will be kept confidential and will be used only to determine if you qualify for the Back On Track Matched Savings Account Program. If you have any questions about the application process or the program itself, please contact Cate Mart, the Back On Track Coordinator at United Way of the Bluegrass: ext 272. NOTE: Applicants MUST currently have EARNED INCOME for program consideration. Name: _ Social Sec. No.: - - Gender: Female Date of birth: / / Male Street Address: Apt #: City: State: Zip Code: Home Phone: ( ) Alternate Phone: ( ) Mailing Address (if different from above): KTAP/TANF: Currently Eligible Currently Receiving Has Ever Received Federal Earned Income Tax Credit: Currently Eligible Currently Receiving Has Ever Received How many adults (18 years and older) currently live in your household? (include yourself) How many children (under 18 years) currently live in your household? Income Information Gross Yearly HOUSEHOLD Income (Before Taxes): Other Income Yes No Annual Amount, if Yes Alimony Child Support SSI/SSDI Food Stamps 1

5 Assets Value Balance Due Do you own your primary residence? Yes No $ $ Do you own other homes? Yes No $ $ Do you own a business? Yes No $ $ Do you own other real estate or land? Yes No $ $ Do you own stocks, bonds, 401k, Yes No $ $ or other investments? Do you currently have a checking account? Yes No $ (Amount in account) Do you have a personal savings Yes No $ (Amount in Account) account? Do you own a vehicle(s)? Yes No Make Model Mileage 1. $ $ 2. $ $ Liabilities Amount/Value Do you have past due household bills? Yes No $ Do you have outstanding student loans? Yes No $ Do you have outstanding medical bills? Yes No $ Do you have outstanding personal loans? Yes No $ Are you carrying a credit card balance? Yes No $ Do you have outstanding payday loans? Yes No $ Do you have any other liabilities? Yes No $ 2

6 Personal Information Ethnicity: African American Caucasian/white Latino or Hispanic Asian, Pacific Islander Native American Other: Do you have experience with Direct Deposit? Yes Marital Status: No Single (never married) Married Separated Divorced Widowed Employment Status (Choose One): Employed more than full-time Employed part-time Working and in school or job training Laid off, waiting for call back Currently in school or job training Employed full-time Currently seeking employment Homemaker, not seeking employment Disabled, not seeking employment Retired, not seeking employment Highest level of education completed: Grade K through 5 Grade 6 through 8 Grade 9 through 12 High school diploma or GED Place of residence: Major Urban or Suburban (population of 2,500 or more) Small Town or Rural (population of less than 2,500) For which primary asset do you plan to save? Attended or currently enrolled in college Attained 2 year degree Attained 4 year degree Graduated or currently attending graduate school Home ownership Education Business ownership How much do you think you could afford to save each month? $ Do you plan to use direct deposit for your Back On Track account? Yes No Do you plan to deposit a portion of the Earned Income Tax Credit, if received, into your Back On Track account? Yes No If you were to receive the average Earned Income Tax Credit of $2,000, how much would you deposit into your Back On Track account? $ 3

7 Employment Information Employer: Phone: ( ) Street: City or Town: State: Zip Code: Have you changed jobs in the last six months? Yes No If yes, please explain: How many other members of the household are employed either full or part-time? Please include ALL children and adults in the household who are formally employed and list them in the section below: Name of household member Employer name Employer phone number How did you learn about Back On Track? UWBG UWBG Website Agency: Friend Tax Site Other: Please explain any special needs that the Back On Track Coordinator should know about: 4

8 Applicant Personal Statement Please explain why you are interested in participating in Back On Track, including your choice of asset: Emergency Contact Information Please list a relative or friend who does not live with you and would definitely know how to contact you: Name: Phone: ( ) Street: Apt #: City: State: Zip Code: Necessary Documentation Please provide the following documentation so that we may verify your earned income. Back On Track MUST have the necessary documentation before we can determine your eligibility: Current Pay Stub Wage statements for ALL members of your household who have earned income (program eligibility is determined by HOUSEHOLD income) Statements from employers indicating that the applicant has at least six months of steady employment Statements from landlords or mortgage companies indicating that the applicant has at least six months of good standing in rent/house payments Proof of Checking and/or Savings Account 5

9 Additional Documentation If applicable, please also provide the following necessary documentation: Proof of Automobile Insurance Proof of Government Assistance: KTAP/TANF, food stamps, SSI, SSDI, unemployment or veterans benefits, etc. Proof of Pension or Retirement Income Proof of 401K or Investment Income Once you have the necessary documentation, you may return your completed Back On Track application to the following address: United Way of the Bluegrass Attn: Michael Burke 2480 Fortune Drive, Suite 250 Lexington, KY Ph: ext. 238 Fax: http: NOTE: Applications MUST be complete and include necessary documentation in order to be processed. Applicant Certification My signature below certifies that all information provided on this application is accurate and complete to the best of my knowledge. Furthermore, I agree to pull a credit report from a credit bureau every 6 months during my enrollment of the program and agree to allow Back On Track to follow up with me for up to two years following my graduation. Applicant Signature: Date: 6

10 Employment Verification Date This is to verify that (employee name), as an applicant for the Back On Track Matched Savings Account Program, is an employee in good standing at (company name), and has been employed for (length of time). Employer/Manager Signature Print Name Clearly Phone Number If you have any questions please feel free to call Cate Mart at (859) ext Cate Mart Financial Stability Coordinator United Way of the Bluegrass 2480 Fortune Drive #250 Lexington, Kentucky tel ext. 272 fax

11 Housing Verification Date This is to verify that (tenant name), as an applicant for the Back On Track Matched Savings Account Program, is a resident in good standing at (address), and has resided at this address for (length of time). Landlord/ Residence Manager Signature Print Name Clearly Phone Number If you have any questions please feel free to call Cate Mart at (859) ext Cate Mart Financial Stability Coordinator United Way of the Bluegrass 2480 Fortune Drive #250 Lexington, Kentucky tel ext. 272 fax cate.mart@uwbg.org