Potomac Soccer Association
Financial Assistance Application Fall 2017 - Spring 2018 Potomac Soccer Association is proud to provide a need-based financial assistance program for families to offset fees associated with participating on a Potomac Soccer Association team. All applicants' names and information is held in strict confidence by our administrator. To apply, please complete this form and submit it fully completed, with required documentation. Notification of financial assistance awards will come via email. Please allow 2-3 weeks for processing.
Important Information and Instructions Application Deadline: Completed application and required documentation due within 10 days of player registration. A deposit of $150 must be paid in order for a financial assistance application to be considered. This can be paid by check or cash upon submitting the application. A $35 returned check fee will be assessed for returned checks. Applications will not be reviewed or considered if not legible, or if any information or documentation is missing. Complete applications are reviewed in the order in which they are received, on a rolling basis. Funds are limited. The number of players receiving financial assistance and the amount of assistance will vary depending on available funds. Award notifications will be made by e-mail to Blue Sombrero Account Holder responsible for player fees and through email as needed. Families will be responsible for paying any uniform, travel, or other team and club expenses not covered by this financial assistance. Applications are reviewed by the administrator. All information is kept in the strictest of confidence. A committee reviews blind applications. Please keep a copy for your records
Families are also encouraged to apply for other grants or financial assistance to help them with fees and other player related expenses.
Send completed form and required documentation to: Potomac Soccer Association, Mail: P.O. Box 60227, Potomac, MD 20859 Fax: 240-396-5667 (confidential) email: [email protected]
Children participating in a Potomac Soccer program for the Fall 2017 – Spring 2018 season Child Last Name
Child First Name
Date of Birth
Age Group
Coach
For Office Use
Are parents divorced? ___No ___Yes If yes, Date of Divorce (month/year): __________ Are parents separated? ___No ___Yes If yes, Date of Separation (month/year): __________ Is custody shared? __Yes __ No If no, name of custodial parent(s):_______________________________ Amount family feels they can pay toward PSA fees for the 2017-2018 season: $______________ Who is responsible for PSA fees? Name______________________________ Relationship_______________ ______% Name______________________________ Relationship_______________ ______% If tuition is shared, each responsible party must complete a financial aid application.
Parent/Guardian or Adult A (responsible for payment) Name:____________________________________________ Relationship to Player(s):______________________ First
Last
Address:______________________________________________________________________________________ Street
Phone:__________________________
City
____________________________
Home
State
Zip
_____________________________
Cell
Work
Occupation:_____________________________ Employer:_____________________________ How Long?_______ Salary: $________________ per year
or $__________________ per hour; ______________hours per week
Are you self employed? ___Yes ___No Marital Status: __Married
__Separated __Single, divorced __Single, widowed __Single, never married
Do you pay child support? Do you receive child support?
__No __Yes __No __Yes
if yes, amount: $_________/year if yes, amount: $_________/year
Parent/Guardian or Adult B (co-responsible for payment, or other adult residing in household) Name:____________________________________________ Relationship to Player(s):______________________ First
Last
Address:______________________________________________________________________________________ Street
Phone:__________________________
City
____________________________
Home
State
Zip
_____________________________
Cell
Work
Occupation:_____________________________ Employer:_____________________________ How Long?_______ Salary: $________________ per year
or $__________________ per hour; ______________hours per week
Are you self employed? ___Yes ___No Marital Status: __Married
__Separated __Single, divorced __Single, widowed __Single, never married
Do you pay child support? Do you receive child support?
__No __Yes __No __Yes
if yes, amount: $_________/year if yes, amount: $_________/year
List all additional members of household: _______________________________________________________________________________________________ Name
Age
Relationship to Player
_______________________________________________________________________________________________ Name
Age
Relationship to Player
_______________________________________________________________________________________________ Name
Age
Relationship to Player
_______________________________________________________________________________________________ Name
Age
Relationship to Player
Parent, Guardian
Parent, Guardian
or Adult A
or Adult B
Family Income Verification
Total Household
W-2 Wages (total from all employers)
$
$
$
Interest/Dividend Income
$
$
$
Net Business Income (from self employment, farm, rental & other businesses) - Form 1040 Schedule C, E, and/or F
$
$
$
Other Non-Work Taxable Income (unemployment and non-business income)
$
$
$
Alimony Received
$
$
$
Child Support Received
$
$
$
Other Income - describe source(s) such as gifts from family/friends, etc.
$ $ $
$ $ $
$ $ $
Total Income
$
$
$
Do you rent or own your residence? __Rent __ Own If yes, the current property value is $_______________, and the mortgage balance is $______________ What is your monthly rental or mortgage payment? $_______________ Total amount in cash/checking and savings accounts: $______________ Do you own property in addition to your primary residence? __Yes ___No If yes, the current property value is $_______________, and the mortgage balance is $______________ Do you own a business? __Yes __ No If yes, does your business pay any of your automobile or other personal expenses? __Yes __No If yes, list Expense type ___________________________, and annual amount $_______________ Expense type ___________________________, and annual amount $_______________ Expense type ___________________________, and annual amount $_______________
For dependent children attending private school or college: Child Name
School
Grade or Year
Total Tuition $
Aid Received $
Amt Paid by Others $
Amt Paid by Family $
Please describe any special circumstances that you feel should be taken into account to better understand your request for financial aid. If more space is required, attach an additional sheet if necessary to continue explanation.
I/we will be applying for other grants or financial aid to aid with the costs of participating in a Potomac Soccer Association program. ___Yes ___No If yes, list from where and amounts._____________________ $__________ I/we declare that the information in this application is accurate, complete, and up-to-date, to the best of my/our knowledge. I understand that providing wrong or incomplete information may result in the forfeit of financial aid. I agree to apply for other financial aid or grants my child may be eligible for, to offset fees already adjusted by the Potomac Soccer Association. Parent/Guardian A: _____________________________
_____________________________
Signature
Parent/Guardian B: _____________________________
Printed Name
_____________________________
Signature
Printed Name
A copy of the following forms must be included with this application: Current U.S. Federal Tax Return (Form 1040), with all schedules All 2012 W-2s and 1099 Misc forms Proof of eligibility for Free Lunch Program or Food Stamps, if applicable Send completed form and required documentation to: Potomac Soccer Association, Mail: P.O. Box 60227, Potomac, MD 20859 Fax: 240-396-5667 (confidential) e-mail: [email protected] Please keep a copy of your application for your records.
__________________ Date
__________________ Date
Important Information and Instructions Application Deadline: Completed application and required documentation due within 10 days of player registration. A deposit of $150 must be paid in order for a financial assistance application to be considered. This can be paid by check or cash upon submitting the application. A $35 returned check fee will be assessed for returned checks. Applications will not be reviewed or considered if not legible, or if any information or documentation is missing. Complete applications are reviewed in the order in which they are received, on a rolling basis. Funds are limited. The number of players receiving financial assistance and the amount of assistance will vary depending on available funds. Award notifications will be made by e-mail to Blue Sombrero Account Holder responsible for player fees and through email as needed. Families will be responsible for paying any uniform, travel, or other team and club expenses not covered by this financial assistance. Applications are reviewed by the administrator. All information is kept in the strictest of confidence. A committee reviews blind applications. Please keep a copy for your records
Families are also encouraged to apply for other grants or financial assistance to help them with fees and other player related expenses.
Send completed form and required documentation to: Potomac Soccer Association, Mail: P.O. Box 60227, Potomac, MD 20859 Fax: 240-396-5667 (confidential) email: [email protected]
Children participating in a Potomac Soccer program for the Fall 2017 – Spring 2018 season Child Last Name
Child First Name
Date of Birth
Age Group
Coach
For Office Use
Are parents divorced? ___No ___Yes If yes, Date of Divorce (month/year): __________ Are parents separated? ___No ___Yes If yes, Date of Separation (month/year): __________ Is custody shared? __Yes __ No If no, name of custodial parent(s):_______________________________ Amount family feels they can pay toward PSA fees for the 2017-2018 season: $______________ Who is responsible for PSA fees? Name______________________________ Relationship_______________ ______% Name______________________________ Relationship_______________ ______% If tuition is shared, each responsible party must complete a financial aid application.
Parent/Guardian or Adult A (responsible for payment) Name:____________________________________________ Relationship to Player(s):______________________ First
Last
Address:______________________________________________________________________________________ Street
Phone:__________________________
City
____________________________
Home
State
Zip
_____________________________
Cell
Work
Occupation:_____________________________ Employer:_____________________________ How Long?_______ Salary: $________________ per year
or $__________________ per hour; ______________hours per week
Are you self employed? ___Yes ___No Marital Status: __Married
__Separated __Single, divorced __Single, widowed __Single, never married
Do you pay child support? Do you receive child support?
__No __Yes __No __Yes
if yes, amount: $_________/year if yes, amount: $_________/year
Parent/Guardian or Adult B (co-responsible for payment, or other adult residing in household) Name:____________________________________________ Relationship to Player(s):______________________ First
Last
Address:______________________________________________________________________________________ Street
Phone:__________________________
City
____________________________
Home
State
Zip
_____________________________
Cell
Work
Occupation:_____________________________ Employer:_____________________________ How Long?_______ Salary: $________________ per year
or $__________________ per hour; ______________hours per week
Are you self employed? ___Yes ___No Marital Status: __Married
__Separated __Single, divorced __Single, widowed __Single, never married
Do you pay child support? Do you receive child support?
__No __Yes __No __Yes
if yes, amount: $_________/year if yes, amount: $_________/year
List all additional members of household: _______________________________________________________________________________________________ Name
Age
Relationship to Player
_______________________________________________________________________________________________ Name
Age
Relationship to Player
_______________________________________________________________________________________________ Name
Age
Relationship to Player
_______________________________________________________________________________________________ Name
Age
Relationship to Player
Parent, Guardian
Parent, Guardian
or Adult A
or Adult B
Family Income Verification
Total Household
W-2 Wages (total from all employers)
$
$
$
Interest/Dividend Income
$
$
$
Net Business Income (from self employment, farm, rental & other businesses) - Form 1040 Schedule C, E, and/or F
$
$
$
Other Non-Work Taxable Income (unemployment and non-business income)
$
$
$
Alimony Received
$
$
$
Child Support Received
$
$
$
Other Income - describe source(s) such as gifts from family/friends, etc.
$ $ $
$ $ $
$ $ $
Total Income
$
$
$
Do you rent or own your residence? __Rent __ Own If yes, the current property value is $_______________, and the mortgage balance is $______________ What is your monthly rental or mortgage payment? $_______________ Total amount in cash/checking and savings accounts: $______________ Do you own property in addition to your primary residence? __Yes ___No If yes, the current property value is $_______________, and the mortgage balance is $______________ Do you own a business? __Yes __ No If yes, does your business pay any of your automobile or other personal expenses? __Yes __No If yes, list Expense type ___________________________, and annual amount $_______________ Expense type ___________________________, and annual amount $_______________ Expense type ___________________________, and annual amount $_______________
For dependent children attending private school or college: Child Name
School
Grade or Year
Total Tuition $
Aid Received $
Amt Paid by Others $
Amt Paid by Family $
Please describe any special circumstances that you feel should be taken into account to better understand your request for financial aid. If more space is required, attach an additional sheet if necessary to continue explanation.
I/we will be applying for other grants or financial aid to aid with the costs of participating in a Potomac Soccer Association program. ___Yes ___No If yes, list from where and amounts._____________________ $__________ I/we declare that the information in this application is accurate, complete, and up-to-date, to the best of my/our knowledge. I understand that providing wrong or incomplete information may result in the forfeit of financial aid. I agree to apply for other financial aid or grants my child may be eligible for, to offset fees already adjusted by the Potomac Soccer Association. Parent/Guardian A: _____________________________
_____________________________
Signature
Parent/Guardian B: _____________________________
Printed Name
_____________________________
Signature
Printed Name
A copy of the following forms must be included with this application: Current U.S. Federal Tax Return (Form 1040), with all schedules All 2012 W-2s and 1099 Misc forms Proof of eligibility for Free Lunch Program or Food Stamps, if applicable Send completed form and required documentation to: Potomac Soccer Association, Mail: P.O. Box 60227, Potomac, MD 20859 Fax: 240-396-5667 (confidential) e-mail: [email protected] Please keep a copy of your application for your records.
__________________ Date
__________________ Date
