The Salvation Army Summer Day Camp 2017
Financial Assistance Application ONE per Family
The Salvation Army Summer Day Camp 2017 Regular Rates are $120 Per week, Per Child Please note we accept Child Care Assistance from the State. If both parents living in the house are working we ask that you apply with them first. You can fill out an application online at:
www.dhs.state.il.us
4508 41st Street Moline, IL Phone: (309) 205-3070
Please fill out State application then print it off and bring in all required documents Maximum Monthly Family Income Guidelines for State Child Care Assistance for 2017 is:
Family Size 2-$2,163 Size 3-$2,722 Size 4-$3,281 Size 5-$3,840 Size 6-$4,399 Size 7-$4,959 If you receive TANF Maximum amounts are higher *If you do not meet these guidelines please fill out the form below and we will look at a partial family sponsorship.* Most families receive between 10%-33% off Regular Rates Parent/Guardian Name: __________________________________________ Relation to Child: __________________________ Child(ren’s) Name whom you are applying for assistance: _________________________
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Please list all household members including yourself that have not been listed above: Name Relationship Age Employed Monthly Income _______________________ ________________ _______ Yes No _______________ _______________________ ________________ _______ Yes No _______________ _______________________ ________________ _______ Yes No _______________ _______________________ ________________ _______ Yes No _______________ Total Monthly Income _______________ Please fill in the amount per month if you receive the following: Child Support/Alimony ______ Food stamps or any additional assistance not listed on monthly income__________ FINANCIAL INFORMATION: List or explain any special financial circumstances that impact your ability to pay the full amount of this program at this time (illness, special housing considerations, separation arrangements, etc.) you can write on back if you need more room. **Please indicate how much you could afford each week**
________________________________________________________________________________ ________________________________________________________________________________ AFFIRMATION: I have enclosed the following for documentation: Most recent income tax return(s) AND two recent pay stub for each wage earning adult To the best of my knowledge, the information contained on this form is accurate. The information is subject to review and verification; if it is found that information has been falsified or omitted, I will be no longer eligible and possibly prosecuted for fraud.
Name: ____________________________ Signature: ___________________________ Date:______________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Office Use Only Date Received: ________________ Financial Assistance Awarded ($)______________for the summer: Total Original Amount ($): _______________ per week *** Final Adjusted Amount ($):______________per week Summer Day Camp Director signature: ______________ _______ Date:____________
The Salvation Army Summer Day Camp 2017 Regular Rates are $120 Per week, Per Child Please note we accept Child Care Assistance from the State. If both parents living in the house are working we ask that you apply with them first. You can fill out an application online at:
www.dhs.state.il.us
4508 41st Street Moline, IL Phone: (309) 205-3070
Please fill out State application then print it off and bring in all required documents Maximum Monthly Family Income Guidelines for State Child Care Assistance for 2017 is:
Family Size 2-$2,163 Size 3-$2,722 Size 4-$3,281 Size 5-$3,840 Size 6-$4,399 Size 7-$4,959 If you receive TANF Maximum amounts are higher *If you do not meet these guidelines please fill out the form below and we will look at a partial family sponsorship.* Most families receive between 10%-33% off Regular Rates Parent/Guardian Name: __________________________________________ Relation to Child: __________________________ Child(ren’s) Name whom you are applying for assistance: _________________________
__________________________
_________________________ ___________________________
Please list all household members including yourself that have not been listed above: Name Relationship Age Employed Monthly Income _______________________ ________________ _______ Yes No _______________ _______________________ ________________ _______ Yes No _______________ _______________________ ________________ _______ Yes No _______________ _______________________ ________________ _______ Yes No _______________ Total Monthly Income _______________ Please fill in the amount per month if you receive the following: Child Support/Alimony ______ Food stamps or any additional assistance not listed on monthly income__________ FINANCIAL INFORMATION: List or explain any special financial circumstances that impact your ability to pay the full amount of this program at this time (illness, special housing considerations, separation arrangements, etc.) you can write on back if you need more room. **Please indicate how much you could afford each week**
________________________________________________________________________________ ________________________________________________________________________________ AFFIRMATION: I have enclosed the following for documentation: Most recent income tax return(s) AND two recent pay stub for each wage earning adult To the best of my knowledge, the information contained on this form is accurate. The information is subject to review and verification; if it is found that information has been falsified or omitted, I will be no longer eligible and possibly prosecuted for fraud.
Name: ____________________________ Signature: ___________________________ Date:______________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Office Use Only Date Received: ________________ Financial Assistance Awarded ($)______________for the summer: Total Original Amount ($): _______________ per week *** Final Adjusted Amount ($):______________per week Summer Day Camp Director signature: ______________ _______ Date:____________
