First Name Please enter the first name of the primary household adult in this field. More The primary household adult is the adult living in the household who will be the main contact for any membership, programs, child care, or financial assistance at the Y. Last Name Please enter the last name of the primary household adult in this field. More The primary household adult is the adult living in the household who will be the main contact for any membership, programs, child care, or financial assistance at the Y. Date of Birth Please enter the primary household adult's date of birth in this field. Gender Male Female Please enter the gender of the primary household adult. Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Phone Email Email Confirm Email Household Residents Household Residents Names and Ages Re-order Name Age Weight Operations Name Age Item weight Add more items Please add the names and ages of everyone living in the household. Type of Assistance You're Requesting (Check all that apply) Membership Check this box if you're applying for income-based membership assistance. Program Check this box if you're applying for income-based program assistance. Child Care Check this box if you're applying for income-based child care assistance. Household Income Verification Have you filed for a tax return in the last 12 months? Yes No Would you prefer to verify your income without a tax return? Yes No Please note: Without uploading a tax return, you must provide all income for all members of the household and upload verifying documents for each income source. Upload Tax Return Pleae upload your most recent tax return from within the last 12 months. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Aid to Families for Dependent Children Is anyone in your household receiving Aid to Families with Dependent Children? - Select -YesNo What is AFDC Aid to Families with Dependent Children (AFDC) was established by the Social Security Act of 1935 as a grant program to enable states to provide cash welfare payments for needy children who had been deprived of parental support or care because their father or mother was absent from the home, incapacitated, deceased, or unemployed. Per Month Aid to Families for Dependent Children Documentation Please upload documentation that verifies the dollar value of assistance that you are provided. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. SNAP Food Benefits Is anyone in your household receiving SNAP Food Benefits? - Select -YesNo What is SNAP The Supplemental Nutrition Assistance Program (SNAP) is a federal nutrition program. Known previously as "food stamps," SNAP benefits can help you stretch your food budget if you have a low income. Per Month SNAP Food Benefits Dcoumentation Please upload documentation that verifies the amount of SNAP benefits you recieve each month. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Social Security Benefits Is anyone living in your household receiving Social Security benefits? - Select -YesNo What are Social Security Benefits? The Supplemental Security Income (SSI) program provides support to disabled adults and children who have limited income and resources, as well as people age 65 and older who are not disabled but have limited income and resources. Per Month Social Security Benefits Documentation Please upload documentation that verifies the amount of Social Security Benefits recieved each month. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Veterans or Retirement Benefits Is anyone in your household receiving Veteran's or Retirement Benefits - Select -YesNo What are Veteran's or Retirement Benefits? Veteran's benefits could include disability compensation, pension, and housing assistance. Retirement benefits would include any payments being paid to you from a retirement account. Per Month Veterans or Retirement Benefits Documentation Please upload documentation verifying the amount of veteran's or retirement benefits received monthly. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Child Support Is anyone in your household receiving child support? - Select -YesNo What is Child Support? In family law and public policy, child support (or child maintenance) is an ongoing, periodic payment made by a parent for the financial benefit of a child (or parent, caregiver, guardian, or state) following the end of a marriage or other relationship. Per Month Child Support Documentation Please upload documentation verifying the amount of child support received each month. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Spousal Support Is anyone in your household receiving spousal support? - Select -YesNo What is spousal support? When a married couple gets a divorce, the court may award "alimony" or spousal support to one of the former spouses, based either on an agreement between the couple or a decision by the court itself. This is separate from the division of marital property and is decided on a case-by-case basis. Per Month Spousal Support Documentation Please provide documentation verifying the amount of spousal support recieved. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Employment Is anyone in your household employed? - Select -YesNo More Information on Entering Employment Please add up and enter the total dollar amount per month from anyone in the household combined. Use the amount that is paid on the check (net amount) not the amount before taxes are taken out (gross amount). Per Month Employment Documentation Please upload at least three most recent paystubs for each person in the household who is employed. Maximum 12 files.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Unemployment Benefits Is anyone in your household receiving unemployment benefits? - Select -YesNo What are Unemployment Benefits? Unemployment insurance is a joint federal-state program that provides temporary benefit payments to employees who are out of work through no fault of their own. Please enter the total per month for the entire household. Per Month Unemployment Benefits Documentation Please upload documentation verifying the amount of unemployment benefits recieved monthly. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. What amount do you feel you're able to afford to pay? Per month for membership? For the program you're seeking assistance with? For child care each week? Support for Assistance Please tell us more about your need for assistance and the benefit you/your family would recieve from such assistance. (security question) What color is the sky? CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
First Name Please enter the first name of the primary household adult in this field. More The primary household adult is the adult living in the household who will be the main contact for any membership, programs, child care, or financial assistance at the Y. Last Name Please enter the last name of the primary household adult in this field. More The primary household adult is the adult living in the household who will be the main contact for any membership, programs, child care, or financial assistance at the Y. Date of Birth Please enter the primary household adult's date of birth in this field. Gender Male Female Please enter the gender of the primary household adult. Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Phone Email Email Confirm Email Household Residents Household Residents Names and Ages Re-order Name Age Weight Operations Name Age Item weight Add more items Please add the names and ages of everyone living in the household. Type of Assistance You're Requesting (Check all that apply) Membership Check this box if you're applying for income-based membership assistance. Program Check this box if you're applying for income-based program assistance. Child Care Check this box if you're applying for income-based child care assistance. Household Income Verification Have you filed for a tax return in the last 12 months? Yes No Would you prefer to verify your income without a tax return? Yes No Please note: Without uploading a tax return, you must provide all income for all members of the household and upload verifying documents for each income source. Upload Tax Return Pleae upload your most recent tax return from within the last 12 months. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Aid to Families for Dependent Children Is anyone in your household receiving Aid to Families with Dependent Children? - Select -YesNo What is AFDC Aid to Families with Dependent Children (AFDC) was established by the Social Security Act of 1935 as a grant program to enable states to provide cash welfare payments for needy children who had been deprived of parental support or care because their father or mother was absent from the home, incapacitated, deceased, or unemployed. Per Month Aid to Families for Dependent Children Documentation Please upload documentation that verifies the dollar value of assistance that you are provided. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. SNAP Food Benefits Is anyone in your household receiving SNAP Food Benefits? - Select -YesNo What is SNAP The Supplemental Nutrition Assistance Program (SNAP) is a federal nutrition program. Known previously as "food stamps," SNAP benefits can help you stretch your food budget if you have a low income. Per Month SNAP Food Benefits Dcoumentation Please upload documentation that verifies the amount of SNAP benefits you recieve each month. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Social Security Benefits Is anyone living in your household receiving Social Security benefits? - Select -YesNo What are Social Security Benefits? The Supplemental Security Income (SSI) program provides support to disabled adults and children who have limited income and resources, as well as people age 65 and older who are not disabled but have limited income and resources. Per Month Social Security Benefits Documentation Please upload documentation that verifies the amount of Social Security Benefits recieved each month. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Veterans or Retirement Benefits Is anyone in your household receiving Veteran's or Retirement Benefits - Select -YesNo What are Veteran's or Retirement Benefits? Veteran's benefits could include disability compensation, pension, and housing assistance. Retirement benefits would include any payments being paid to you from a retirement account. Per Month Veterans or Retirement Benefits Documentation Please upload documentation verifying the amount of veteran's or retirement benefits received monthly. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Child Support Is anyone in your household receiving child support? - Select -YesNo What is Child Support? In family law and public policy, child support (or child maintenance) is an ongoing, periodic payment made by a parent for the financial benefit of a child (or parent, caregiver, guardian, or state) following the end of a marriage or other relationship. Per Month Child Support Documentation Please upload documentation verifying the amount of child support received each month. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Spousal Support Is anyone in your household receiving spousal support? - Select -YesNo What is spousal support? When a married couple gets a divorce, the court may award "alimony" or spousal support to one of the former spouses, based either on an agreement between the couple or a decision by the court itself. This is separate from the division of marital property and is decided on a case-by-case basis. Per Month Spousal Support Documentation Please provide documentation verifying the amount of spousal support recieved. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Employment Is anyone in your household employed? - Select -YesNo More Information on Entering Employment Please add up and enter the total dollar amount per month from anyone in the household combined. Use the amount that is paid on the check (net amount) not the amount before taxes are taken out (gross amount). Per Month Employment Documentation Please upload at least three most recent paystubs for each person in the household who is employed. Maximum 12 files.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Unemployment Benefits Is anyone in your household receiving unemployment benefits? - Select -YesNo What are Unemployment Benefits? Unemployment insurance is a joint federal-state program that provides temporary benefit payments to employees who are out of work through no fault of their own. Please enter the total per month for the entire household. Per Month Unemployment Benefits Documentation Please upload documentation verifying the amount of unemployment benefits recieved monthly. One file only.50 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. What amount do you feel you're able to afford to pay? Per month for membership? For the program you're seeking assistance with? For child care each week? Support for Assistance Please tell us more about your need for assistance and the benefit you/your family would recieve from such assistance. (security question) What color is the sky? CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.