YMCA of Western North Carolina

Branch Number

YMCA Identification Number

Todays Month/Day/Year

Financial Assistance
Primary Member Name
Title (Mr., Ms., Dr.) First Name MI Last Name

Residence
Street City State Zip Code

Home Phone ( Birth date ) Male Female Email Employer: Company Name

Membership Type: Choose one of the Following Youth Membership (for individuals 17 years and under) Young Adult Membership ( for individuals between the ages of 18 to 24 years) Adult Membership (for individuals between the ages of 25 to 64 years) Senior Adult Membership (for individuals 65 years and over) Family Membership (for two adults and their dependents under the age of 18 years) Senior Family Membership (for two adults, both over the age of 65, with no dependents) Family Special (for three adults over the age of 18 and their dependentsbased on the membership rate of $89 per month) Choose the Center or Program that you are applying for: Asheville Woodfin Reuter Corpening Aquatics Youth Sports Summer Camp

Financial Information and Required Documentation:

Totally Family Income: Monthly: $_______________ Annually: $_______________ Total Family Expenses: (do not include cell phone bill) Monthly: $_______________ Annually: $_______________ A copy of your most recent 1040 Income Tax Return , (Form 1040 or 1040EZ), is required for all adults listed on account. If married filling separately, forms for both forms are required. If you do not have a copy, call the IRS at (800) 829-1040 to request a copy. (If you did not file faxes last year please contact the IRS at (800) 829-8374 and request a letter of verification for non-filing status or submit a 4506-T to the IRS with box number 7 checked to request verification for non - filling. This from can be found at: http://www.irs.gov/pub/irs-pdf/f4506t.pdf )

How much do you feel that you can afford to pay for your Y Membership each month? $___________

Please use the space below to provide us with any information that you feel is useful in evaluating your need for Financial Assistance. Include why you want to become a member of the YMCA and how do you see the YMCA benefiting you and your family.
__________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

The YMCA of Western North Carolina offers its programs and services to the community in the belief that no one should be turned away for their inability to pay. Through the annual Healthier Communities Campaign, the YMCA provides financial assistance based on need and available resources.

YMCA of Western North Carolina

Financial Assistance
Please read and initial the following:
____ I affirm to the best of my knowledge that the attached information is true and complete. ____ If my situation changes I agree to notify the YMCA of WNC within 30 days ____ I realize that my Financial Assistance Application will not be processed unless all required documentation has been provided.
In accordance with the character values of faith, honesty, respect, caring and responsibility, I verify that the information provided on this application is accurate. I understand that false information will disqualify me from participating in this organization. I understand that the decision to grant a fee reduction is at the sole discretion of the YMCA if funds are available. This is not a guarantee that I will continue to receive a reduction in fees. I understand that failure to renew this financial assistance will terminate my membership status. I understand that it is my responsibility to notify the YMCA of any changes in my personal information including change of address, phone number or changes in my financial situation. Signature of Applicant : __________________________________________________________________ Date: ______________________

Please read and initial your Y Access Schedule:

Date Subsidy Applied Monthly Cost Initials

I understand that my membership will resume at full rate at the end of my Y Access Assistance Schedule noted above: Initials:________

Office Use Only:

Did the member provide documentation for all income that was claimed? Did the member answer all questions on the Financial Assistance Application? Please Check One: Yes Yes No No

New Applicant

Y Access Renewal

Current Member

Previous Membership Date: _____/_____/_____

Previous Subsidy: ________% Monthly Cost: $________

Approved By: _____________________________________ Approved Subsidy: ________% Joining Fee: $_______ Staff Signature:_____________________________________________________________

Date: _____________________