Income and Expense Statement Loan Documents Ny - PDF by iun69772

VIEWS: 11 PAGES: 2

Income and Expense Statement Loan Documents Ny document sample

More Info
									I, ___________________________ , do hereby certify that I have read and completed the attached YMCA of
Greater New York Scholarship & Financial Assistance Application indicating the total number of persons in my
household and the total gross annual income received during the past twelve(12) months as required to
determine eligibility to participate in YMCA programs on the basis of low/moderate income designation.

This certification is being made with the full knowledge and understanding that this statement and all applicable
documents deemed necessary to substantiate my eligibility is subject to full disclosure and verification by
authorized City of New York and U.S. Department of Housing and Urban Development (HUD) officials.

TERMS OF AGREEMENT
I declare that the aforementioned statements are true and correct to the best of my knowledge. If requested, I
will provide further substantiation of all facts, including current income. I hereby authorize the YMCA of Greater
New York to obtain employment income information verification from my employer. I agree to inform the YMCA
of Great New York of any material change in my financial status and employment.

INCOME / EXPENSE WORKSHEET
Income:
We will need the following information for all adults in the household to verify household   Expense:
income (as applies):                                                                         Please include all expenses listed in your name:
$_____________________________ 1) Your Gross Income Monthly Income                           $_____________________________ 1) Rent / Mortgage (Circle one)
$_____________________________ 2) Other Adult’s Gross Monthly Income                         $_____________________________ 2) Auto Loan
$_____________________________ 3) Child Support                                              $_____________________________ 3) Utilities
$_____________________________ 4) Aid to Dependent Children                                  $_____________________________ 4) Phone
$_____________________________ 5) Welfare (Submit copy of amount received)                   $_____________________________ 5) Child Support
$_____________________________ 6) Food Stamps (Submit copy of amount received)               $_____________________________ 6) Medical
$_____________________________ 7) Reduced Lunch Program (Submit copy of card)                $_____________________________ 7) Child Care
$_____________________________ 8) Social Security / Disability                               $_____________________________ 8) Food
$_____________________________ 9) Unemployment                                               $_____________________________ 9) Credit Cards
$_____________________________ 10) Pension / Retirement                                      $_____________________________ 10) Other (Please explain)
$_____________________________ 11) Alimony                                                                                              _______________________________________
$_____________________________ 12) POC (Purchase of Care)                                                                               _______________________________________
$_____________________________ 13) Other (Please explain)
                                                                                                                                        _______________________________________
                                        _______________________________________
                                        _______________________________________
                                        _______________________________________
                                                                                                                                                                                                            FINANCIAL ASSISTANCE APPLICATION
$______________________ Total Monthly Income
(Documentation attached)                                                                     $______________________ Total Monthly Expense
                                                                                                                                                                                                            . . . so that no one is turned away.
APPLICANT’S SIGNATURE: ____________________________ DATE: _____________________________________




                                                                                                                                                                                  YMCA Mission:
                                                                                                                                                                                  The YMCA of Greater New York is a community service organization which
                                                                                                                                                                                  promotes positive values through programs that build the spirit, mind and body,
                                                                                                                                                                                  welcoming all people, with a focus on youth.
                                                                                                                                                                                                                                                                                                                                                                                                     Financial Assistance Application




                                                                                                                                                                                                       Branch:__________________________ Date:_____________________ Name:____________________________ Member #_________________________
                                                                                                                                                                                                                                                                                                                                          Participant’s Name:________________________________________ Date of Birth:______________________
                                                                                                                                                                                                                                                                                                                                                                                            Child’s School: ___________________________________

                                     What is the Financial Assistance Program?                                                                                                                                                                                                                                                            Financial assistance requested for (Program Name): _______________________________________________
                                                                                                                                                                                                                                                                                                                                          Date:______________ Time: __________________ Session: _______________________________________
                                                                                                                                                                                                                                                                                                                                          Fee (Consult your program guide):______________ PCS Code: _____________________________________
                                                                                                                                                                                                                                                                                                                                                                    Name ______________________________ Date of Birth_________ [ ] M or [ ] F




                                                                                                                                                                                                                                                                                                                                          APPLICANT OR PARENT
                                                                                                                                                                                                                                                                                                                                                                    Home Phone: (___) ____ - ____ Work Phone: (___) ____ - ____ Mobile Phone: (___) ____ - _____
Through the generosity of YMCA contributors, our goal is to have sufficient funds to ensure our YMCA remains available to all. Thanks to our
generous donors to our annual Strong Kids Campaign, we are able to make the YMCA accessible through our Financial Assistance Program.                                                                                                                                                                                                                               Address: _________________________________State:____________ City: ____________ Zip:_______
                                                                                                                                                                                                                                                                                                                                                                    Employer: ___________________________Employer’s Address________________________________
These gifts provide scholarships for individuals and families who want and need YMCA programs but cannot afford them. The YMCA provides
needed opportunity in programs such as day camp, early childhood care, youth sports, water safety, and school age child care. No one is                                                                                                                                                                                                                             Hours Worked Weekly: ___ Monthly Gross Income: _________ Paid: [ ] Weekly [ ] Bi-Weekly [ ] 1st & 15th [ ] Monthly
denied services because of an inability to pay. Contributions come from YMCA members, community members, businesses, and
corporations.                                                                                                                                                                                                                                                                                                                                                       Student: How many credit hours? _________

To evaluate your individual needs, the YMCA requires you share as much information as possible about your financial situation. Certain items                                                                                                                                                                                                                        Name ______________________________ Date of Birth__________ [ ] M or [ ] F




                                                                                                                                                                                                                                                                                                                                          ADULT SPOUSE OR PARTNER
are mandatory and your financial assistance application will be considered incomplete until all those items are submitted. Once the
complete package is received, evaluation takes at least 10 days to process.                                                                                                                                                                                                                                                                                         Home Phone: (___) ____ - ____ Work Phone: (___) ____ - ____ Mobile Phone: (___) ____ - _____
                                                                                                                                                                                                                                                                                                                                                                    Address: _________________________________State:____________ City: ____________ Zip:_______
NOTE: Please do not include any original documentation, as they will not be returned. For your security, all information is confidential and
treated with the utmost sensitivity.                                                                                                                                                                                                                                                                                                                                Employer: ___________________________Employer’s Address________________________________
REQUIRED INFORMATION TO SUBMIT                                                                                                                                                                                                                                                                                                                                      Hours Worked Weekly: ___ Monthly Gross Income: _________ Paid: [ ] Weekly [ ] Bi-Weekly [ ] 1st & 15th [ ] Monthly
[ ] Completed Application Form [ ] A copy of your latest 2006 Income Tax Return (IRS Form1040) with copies of all supporting W-2 forms.
                                                                                                                                                                                                                                                                                                                                                                    Student: How many credit hours? _________
Please provide the following additional information as applies to you:
[ ] A copy of your SSI, Food Stamps, Medicaid or Medicare award letter.                                                                                                                                                                                                                                                                   Marital Status:                       [ ] Single [ ] Married [ ] Divorced [ ] Widowed [ ] Domestic Partnership
[ ] One month of current pay stubs. If you do not receive a pay stub, a salary verification form ACD1038 must be submitted.                                                                                                                                                                                                               Household:                            [ ] Single Adult [ ] Single Adult + Child/Children [ ] Two Adults [ ] Two Adults + Child/Children
[ ] Financial aid forms and a copy of their most recent class schedule (Students only).                                                                                                                                                                                                                                                                                         [ ] Other Family Household (Grandmother/Foster/Other)
[ ] Business income tax return (Self-employed only).                                                                                                                                                                                                                                                                                      Ethnicity:                             [ ] White [ ] Latino/Hispanic [ ] African American/Black [ ] Asian/Pacific Islander [ ] American Indian
[ ] Individuals seeking employment must be registered with the state employment service & submit a copy of their state                                                                                                                                                                                                                    This information is gathered for tracking purposes only and is not considered when making any determinations about financial assistance.
     employment registration card.
[ ] Unemployed applicants must submit copies of their state unemployment documentation.                                                                                                                                                                                                                                                                                         List all Household Members, Including Applicant/Parent, Siblings, and/or Spouse
OPTIONAL INFORMATION                                                                                                                                                                                                                                                                                                                                                          First Name                           Last Name                  Gender          Age      Relationship to Applicant
[ ] Telephone, utility, and other monthly bills (eg. rent) for the previous three months that indicate financial need.
[ ] Letters from a doctor, hospital or other provider detailing a condition that increases your need for the YMCA’s programs or                                                                                                                                                                                                                         1           Applicant
    services and is an extenuating factor in your request for a scholarship.                                                                                                                                                                                                                                                                            2           Spouse
It is the mission of the YMCA to assist individuals who might otherwise not be able to afford our programs and services. Financial                                                                                                                                                                                                                      3           Child 1
Assistance funds are allocated from donations received from our Strong Kids Campaign. Therefore, our ability to grant scholarships is                                                                                                                                                                                                                   4           Child 2
dependent on the availability of these funds.
                                                                                                                                                                                                                                                                                                                                                        5           Child 3
                                                                                                                                                                                                                                                                                                                                                        6           Child 4
                                                                                                                                                                                                                                                                                                                                                        7           Child 5
YMCA of Greater New York | 333 Seventh Avenue; New York, NY 10001 | (212) 630 - 9600     Harlem YMCA | 180 West 135th Street; New York, NY 10030 | (212) 281 - 4100
Bedford-Stuyvesant YMCA | 1121 Bedford Avenue; Brooklyn, NY 11216 | (718) 789 - 1497     International YMCA | 5 West 63rd Street - 2nd Floor; New York, NY 10023 | (212) 912 - 2300
                                                                                                                                                                                                                                                                                                                                                        8           Child 6
Bronx YMCA | 2 Castle Hill Avenue; Bronx, NY 11385 | (718) 792 - 9736                    Jamaica YMCA | 89-25 Parsons Boulevard; Jamaica, NY 11432 | (718) 739 - 6600
                                                                                                                                                                                                                                                                                                                                          COST OF THE MEMBERSHIP OR PROGRAM $________________________________________________________________________
Camping Services YMCA | PO Box 622, 300 Big Pond; Huguenot, NY 12746 | (845) 858 - 2200 Long Island City YMCA | 32-23 Queens Boulevard; Long Island City, NY 11101 | (718) 392 - 7932
Catalpa Center | 69-02 64th Street; Ridgewood, NY 11385 | (718) 821 - 6271               McBurney YMCA | 125 West 14th Street; New York, NY 10027 | (212) 912 - 2300                                                                                                                                                                      I AM REQUESTING FINANCIAL ASSISTANCE IN THE AMOUNT OF $_______________________________________________________
Chinatown YMCA | 273 Bowery; New York, NY 10002 | (212) 912 - 2460                       North Brooklyn YMCA | 570 Jamaica Avenue; Brooklyn, NY 11208 | (718) 277 - 1600                                                                                                                                                                  BRIEFLY EXPLAIN YOUR NEEDS FOR FINANCIAL ASSISTANCE: ___________________________________________________________
Cross Island YMCA | 238 - 10 Hillside Avenue; Bellerose, NY | (718) 659 - 7710           Prospect Park YMCA | 357 Ninth Street; Brooklyn, NY 11215 | (718) 768 - 7100
Dodge YMCA | 225 Atlantic Avenue; Brooklyn, NY 11201 | (718) 625 - 3136                  Staten Island YMCA- South Shore | 3939 Richmond Avenue; Staten Island, NY 10312 | (718) 227 - 3200
                                                                                                                                                                                                                                                                                                                                          ____________________________________________________________________________________________________________
Eastern District YMCA | 125 Humboldt Street; Brooklyn, NY 11206 | (718) 782 - 8300       Staten Island YMCA - Broadway Center | 651 Broadway; Staten Island, NY 10310 | (718) 981 - 4933                                                                                                                                                  ____________________________________________________________________________________________________________
Flatbush YMCA | 1401 Flatbush Avenue; Brooklyn, NY 11210 | (718) 469 - 8100              Staten Island YMCA - Counseling Services | 3911 Richmond Avenue; Staten Island, NY 10312 | (718) 966 - 6605
                                                                                                                                                                                                                                                                                                                                          ____________________________________________________________________________________________________________
Flushing YMCA | 138-46 Northern Boulevard; Flushing, NY 11354 | (718) 961 - 6880         Vanderbilt YMCA | 224 East 47th Street; New York, NY 10017 | (212) 756 - 9600
Greenpoint YMCA | 99 Meserole Avenue; Brooklyn, NY 11222 | (718) 389 - 3700              West Side YMCA | 5 West 63rd Street; New York, NY 10023 | (212) 875 - 4100                                                                                                                                                                       ____________________________________________________________________________________________________________
                                                                                                                                                                                                                                                                                                                                          ____________________________________________________________________________________________________________

								
To top