FINANCIAL ASSISTANCE

The mission of the YMCA of Dodge County is to put Christian principles into practice through programs that build healthy spirit, mind, and body for all. Through the generosity of our members, staff, community and Annual Campaign donations, we are able to provide financial assistance for children and families who need it most. We want to help people of all ages and from all walks of life be more healthy, confident, connected, and secure.

Application Requirements:

• Applicants must fill out the Financial Assistance Application, and provide verification of all income and/or assistance received. Applications are kept confidential.

• Assistance may be granted on the basis of financial need such as low income, number of dependents, extenuating circumstances, etc.

• Foster parents must submit proof of household income, along with assistance granted for the child.

• The YMCA conducts regular sex offender screenings on all members, participants and guests. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation and remove visitation access.

• Applicants applying for a membership will need to provide verification of income for all adults in the household.

• Some programs are not eligible for Financial Assistance.

1. *

I am applying for:

Family		Adult (19-59)
Two Adult (20-59)		Senior (60+)
Senior Two Adult (60+)

2. *

Type of Application:

I am a new applicant to the Financial Assistance Program

I am reapplying for the Financial Assistance Program

Applicant Information

3. *	Full Name (First, Middle, Last):

4. *	Date of Birth:

5. *

Gender:

Male		Female
Prefer not to say

6. *	Home Address:

7. *	City:

8. *	State:

9. *	Zip Code:

10. *	Primary Phone Number:

11. *	Secondary Phone Number:

12.	Spouse/Significant Other's Full Name ( First, Middle, Last):

13.	Date of Birth:

INCOME VERIFICATION INFORMATION

Please list the monthly totals for income and/or assistance received by your household. Verification of these amounts is required. You must provide your most recently filed tax return (1040/1040EZ) or Verification of Non-Filing (4506-T), and all applicable supporting documentation of the following:

14. *	Household Gross Monthly Income:

15. *	Upload File Here:
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16.	Food Share Total Monthly (SNAP):

17.	Upload File Here:
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18.	Unemployment Benefits Total Monthly:

19.	Upload File Here:
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20.	Child Support / Alimony Total Monthly:

21.	Upload File Here:
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22.	WI Shares/Childcare Subsidy Total Monthly:

23.	Upload File Here:
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24.	Housing Subsidy Total Monthly (amount of assistance you recieve, not the amount you pay):

25.	Upload File Here:
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26.	Energy Assistance Total Monthly:

27.	Upload File Here:
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28.	Social Security Disability Total Monthly:

29.	Upload File Here:
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30.	Supplemental Social Security Total Monthly:

31.	Upload File Here:
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32.	Other Souces of Income:

33.	Upload File Here:
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Expenses

34.	Rent/Mortgage Total Monthly:

35.	Upload File Here:
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36.	Total Monthly Utilites )Electric, Water/Sewer, Gas) * DO NOT include cable, phone or internet access/lines:

37.	Upload File Here:
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38.	Insurance Total Monthly (Medical, Dental, Vision):

39.	Upload File Here:
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40.	Child Care Total Monthly:

41.	Upload File Here:
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42.	Vehicle Payment/Insurance Total Monthly:

43.	Upload File Here:
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44.	Other Total Monthly Expenses:

45.	Upload File Here:
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Ways to request a non-filing verification for the IRS

ONLINE REQUEST

Available at: www.irs.gov Note: This is typically not available if you have never filed taxes in previous years. If this is the case, please use the paper request process detailed below.

TELEPHONE REQUEST

Available from the IRS by calling 1-800-908-9946

Note: This is typically not available if you have never filed taxes in previous years. If this is the case, please use the paper request process detailed below.

PAPER REQUEST FORM: IRS Form 4506-T

Best option for those who have not filed taxes in recent years. Verifications will be received within 5-10 business days. Processing may take longer during tax season, but the IRS will still issue non-filing verifications.

Download IRS Form 4506-T at: www.irs.gov/pub/irs-pdf/f4606t.pdf

SIGNATURE

46. *	I affirm to the best of my knowledge that the above information is true and complete. I agree to provide income documentation as requested. I understand that this financial assistance is short term, and that financial assistance eligibility is reassessed annually unless otherwise noted.
	By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Financial Aid Form