Maui Family YMCA Financial Assistance Application

Maui Family YMCA

Financial Assistance Application

Confidential

Please FILL OUT ALL information on this Financial Assistance (FA) application and ATTACH the required documents (by scanning or taking a picture and using the File Upload tool at the end of this application). Failure to complete application and provide required documents will delay or deny application review. PLEASE ALLOW A MINIMUM OF Three WEEKS FOR THIS APPLICATION TO BE PROCESSED (APPROVED OR DISAPPROVED) BY THE YMCA.  Fees must be paid at the time of registration, after recieving your award letter and prior to the program start date. Please complete each section as best and fully as possible when filling out application.  THANK YOU.


APPLICANT INFORMATION

If applying for yourself please enter your information below. If applying on behalf of a child or multiple children, please enter the full name of each child in separate boxes below.

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Numerical values only, no dashes.
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DESCRIPTION OF NEED FOR FINANCIAL ASSISTANCE

Are there any special considerations we should take into account when evaluating your application?

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Are you a single parent household?*

FINANCIAL INFORMATION

All information contained in this section will remain confidential and will only be used to evaluate your eligibility to receive financial assistance and the amount of such aid.

Who is the income provider of the household?*

Please list the names of all household members, include yourself, indicating their ages that are being supported by the income provider(s) of the household:

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EMPLOYEMENT INFORMATION

1st Income Provider's Employer Information

2nd Income Provider's Employer Information
(if applicable)


GROSS MONTHLY INCOME / EXPENSES

Please list the gross monthly income and expense items of the income provider(s). Income verification documents (i.e. 1040 Tax Forms, gov’t aid or pmts) must be attached to this application. No application will be processed without proper documentation.


Monthly Income

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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please enter total of all listed above.

Monthly Expenses

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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please round to the nearest whole number, put a 0 if not applicable.
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Please enter total of all listed above.

PROOF OF INCOME

You will NOT be able to submit your application without uploading proof of income. Providing false income will disqualify applicant from consideration.

Proof of Income Examples (for all members of the household)

  • Most current 1040 Federal Tax Return
  • Proof of any and all County/State/Federal Aid
  • Documents indicating Child Support Pmts Received
  • Income already “on file” is not applicable

Attach proof of income and any other applicable supporting documentation by either scanning or taking a picture and uploading with the tools below. Please note: only one attachment per upload tool.

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Only one document is required. If you wish to attach additional documents, you may use the optional upload tools below.

RELEASE AND ACKNOWLEGMENT

By filling out this application and acknowleging below, I give permission to the Maui Family YMCA to use the enclosed and attached information to evaluate my eligibility for financial assistance.  I declare that the statements on this application are correct. I understand that the above information is confidential.

I also acknowledge that I am aware of the rules and policies of the Maui Family YMCA Financial Assistance Program as listed under the YMCA Financial Assistance Guidelines. I understand that to remain eligible for the financial assistance I have received; I must be a YMCA participant in good standing and in compliance with the following terms:

  1. I agree to pay all required fees by their due date.  I understand that any delinquencies in payments (i.e. late payments, returned checks) may result in termination of financial assistance and suspension from the corresponding program.  All unpaid balances must be paid in full prior to renewing membership or signing up for a program.
  2. I agree to obey the house rules of the Maui Family YMCA.  I understand that failure to abide by the rules may result in termination of my YMCA membership and / or financial assistance.
  3. I understand that I am responsible for turning in a renewal application.  Each financial assistance grant lasts for a specific program / session / date.  As a financial assistance recipient, I am responsible for turning in my renewal application with the proper documentation at least three weeks before the beginning of the program.
  4. I understand that no financial assistance grant will be applied retroactively if I decide to purchase a program/membership at full price before I receive my award letter.
  5. I have attached the required income documents.
  6. I understand that scholarship memberships cannot be put on Freeze.
Acknowledgement and Agreement*