Financial Assistance Application

Please fill out the following information and attach the necessary documents (photocopies only) and return to, Tina M. Hoehn- Figura, the Executive Director of the Wayne County YMCA. 105 Park Street, Honesdale, PA. 18431. (570) 253-2083.

Please PRINT all information: Date of application: __________________

Name _______________________________ Home Phone _______________________

Address _________________________ City _______________ State_____ Zip __________

Are you a full-time student? ______ If yes, where? ___________________________________

Are you a single parent household? _____ If no, is spouse a full-time student? ______

List the names (last names, too, if different from applicant) and ages of all persons in the household. Your household includes dependents you claim on your federal income tax returns.
Name Age School/Employer Birth date
Spouse 

List all dependents you claim on your Federal Income Tax Return
1 
2 
3 
4 
5 
6 
7 
8 
9 

This application is for financial assistance for:

Membership (choose one)

Preschool Jr. Youth Sr. Youth Adult Family 

Program - name ____________________

Day Camp – which weeks _____________ 

Other: ___________________________________________________ 

Have you ever applied for financial assistance before? Yes No

If yes, for what program? ____________________________ In what year? _______________
INCOME/EXPENSE WORKSHEET
Income: Expense:
$ __________ 1) Your Gross Monthly Income $ __________1) Rent/Mortgage 

$ __________ 2) Spouse’s Gross Monthly Income $ __________ 2) Auto Loan

$ _________ 3) Child Support $ __________ 3) Utilities

$ __________ 4) Aid to Dependent Children $ __________ 4) Phone 

$ __________ 5) Welfare (submit copy of card) $ __________ 5) Child Support

$ __________ 6) Food Stamps $ __________ 6) Medical

Y_____ N____ 7) Reduced Lunch Program? $ __________7) Child Care

$ __________ 8) Other (Please Explain) $ __________ 8) Other (Please Explain)
___________________________________ ___________________________________
___________________________________ ___________________________________

$ __________ TOTAL MONTHLY INCOME $ __________ TOTAL MONTHLY EXPENSE

$ __________ TOTAL ANNUAL INCOME (HOUSEHOLD)

What is the dollar amount that you are willing to pay or have the ability to pay each month?
Membership $ __________ per month

Program $ __________ per session

Day Camp $ __________ per week

What benefits do you see in having this scholarship to join the Y as a member or participant?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

What are the circumstances that lead to your need for financial assistance?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I verify that all the information submitted is correct, complete and accurate. If my situation changes, I agree to notify the Y within 30 days. If I submit false or inaccurate information, or fail to notify the Y within 30 days, I may be terminated from the Financial Assistance Program.

____________________________ ___________________________ _________________
Signature of Applicant Printed Name of Applicant Date

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