Financial Assistance Application Please fill out all of the fields below. If you have any questions regarding Financial Assistance, please email Jinnette Holguin. Name Mailing Address City State Zip Code Cell Phone Home Phone Email If an applicant is under 18: Parent's or legal guardian's name Please check each family member applying for financial assistance: Parent/Guardian/Adult Parent/Guardian/Adult Child 1 Child 2 Child 3 Child 4 Child 5 Other Dependent(s) Check the category for which your are applying: Family Adult (Age 29+) Senior (Age 55+) Teen (Ages 10-18) Other Child Care Day Camp What other options of Chilcare are available to you? What do you feel you can afford to pay for this membership/program? Who has custody of the children? Joint Mom Dad Foster Guardian I do not have custody Not Applying for Childcare Parent/Guardian #1 Working At Home In School N/A Parent/Guardian #2 Working At Home In School N/A COPIES OF ALL DRIVERS' LICENSES A PERSONAL LETTER EXPLAINING YOUR NEED FOR ASSISTANCE COPIES OF YOUR TWO PAYCHECK STUBS IF YOU FILED FOR FEDERAL TAXES LAST YEAR - COPY OF LATEST TAX RETURN - (Please include your "Schedule C" worksheet if line 12 has been completed on your 1040 Tax Return Form) OR IF YOU DID NOT FILE FEDERAL TAXES FOR LAST YEAR OR HOUSEHOLD INCOME HAS CHANGED SINCE YOU LAST FILED FOR TAXES LAST YEAR -COPY OF MOST RECENT TRANSCRIPT FROM IRS at https://www.irs.gov/individuals/get-transcript (Please submit either document) Please read the following: By clicking the SUBMIT button above, you understand that you must provide verification of your income upon application for membership. You also understand that as a Georgia Mountains YMCA member, you must re-apply, providing updated income verification every year. Failure to re-apply will result in my membership reverting to the full pay amount. I certify that the above information is true and complete to the best of my knowledge, and that I do not have additional income not represented above. I agree, if necessary, to send additional information and documentation to support the above statements. I understand that sponsorship assistance is based on need. In the event that I or my children must cancel our participation, I will contact the YMCA immediately so sponsorship can be provided to others. I understand that if I falsify any of the above information, I will not be eligible for assistance now and/or in the future. SUBMIT This application must be renewed every 12 months!