Child Care Financial Assistance Application Child Care Financial Assistance Application First and Last Name * Email Address * Phone Number * Income Verification Guide Questions The Rappahannock Area YMCA is able to provide membership and program assistance through the generosity of our donors. Please complete and submit this form. If you are not required to file taxes, you will need to provide a minimum of (but not limited to) 2 documents showing your projected yearly income, financial support and proof of dependents. Note: Information provided will be kept confidential. Please include verification of all residents. If there is no current verification, zero income or no income, the financial assistance application cannot be processed. Household Size In order to process your evaluation, we require two (2) months of bank statements and a copy of your Driver's License. Please upload those below. Bank Statement & Driver's License Upload * Drop a file here or click to upload Choose File Maximum upload size: 2MB Please follow the instructions below to provide us with documentation of all sources of income. 1. Did you or your family file taxes? * Yes No - if no, go to question #3. If you answered YES to question #1: – If filed individually, please submit 1040 for all adults in household. If filed jointly, please submit jointly filed 1040. If self-employed, please include 1040 Schedule C with 1040 documentation. Then proceed to question #2. 1040 Tax Form File Upload Drop a file here or click to upload Choose File Maximum upload size: 2.1MB 2. Does your 1040 accurately reflect your current household income and dependents? Yes No 3. Are you or any other adult in your household currently employed? * Yes No - if no, please proceed to question #4 If you answered YES to question #3 please upload the 2 most recent pay stubs or an offer letter for each working adult in the household. Then proceed to question #4. Pay Stubs/Offer Letter File Upload Drop a file here or click to upload Choose File Maximum upload size: 2MB 4. Are you or any other adult in your household receiving Social Security or drawing from a pension/retirement plan? * Yes No - if no, proceed to question #5 If you answered YES to question #4: – Please provide SSI documentation and 3 months of bank statements showing SSI Direct Deposit. If drawing from a pension/retirement fund, please provide 1099 and 3 months of bank statement showing Direct Deposit of funds. Then proceed to question #5. SSI/Pension/Retirement File Upload Drop a file here or click to upload Choose File Maximum upload size: 2MB 5. Are you or any other adult in your household receiving Unemployment/SNAP/TANF/Disability/child support/alimony? * Yes No - if no, proceed to question #6 If you answered YES to question #5: Please provide statement of benefits and 3 months of bank statements. Then proceed to question #6. Other Income File Upload Drop a file here or click to upload Choose File Maximum upload size: 2.1MB 6. Do you have any adult dependents (18 & older) living in your household? * Yes - if yes, please proceed to question #7 No - if no, please proceed to question #9 7. Are they ages 18-25 and full-time college students? (12 or more undergraduate credits or enrolled in a graduate program) Yes - Please provide full-time class schedule for the upcoming semester. No - if no, proceed to question #8 College Schedule Upload Drop a file here or click to upload Choose File Maximum upload size: 2MB 8. Are the additional adults (18 years or older) employed or receiving any type of government assistance? Yes - – If yes, please provide documentation pertaining to source of income (see questions 1 – 5) and proceed to question #9 No - if no, proceed to question #9 9. What additional circumstances would you like us to consider? * By signing this form, I certify that the information provided to the YMCA is true and all income is reported. I also acknowledge it is necessary to notify the YMCA of any change in my income or financial support. Open Doors Renewal Policy: I understand that after every 12 months of membership my Open Doors discount will decrease by 10% (for both programs and membership). I understand that in order to continue to receive the same Open Doors discount, I am responsible for submitting a new Open Doors application with current financial documentation each year, in the month prior to my annual renewal date. I understand that failure to submit renewal paperwork will result in an increase of my monthly membership dues and the cost of any Y programs. I authorize the Rappahannock Area YMCA to charge my account appropriately based upon the fee schedule outlined above. Signature Clear reCAPTCHA If you are human, leave this field blank.
