Financial Assistance | Documentation Review & Executive Approval Requests

MEMBERSHIP:
No documentation review for approval. Once approved, members are subject to a quarterly random audit. When a member is selected for audit, they have 30 days to bring their documentation in for review. Memberships will terminate if documentation is not brought in when requested. Audit activity is managed by YSC.

Request for Additional Assistance - complete this form for applicants requesting 70% assistance.

PROGRAMS:
Income Documentation Review:
1. Ask the applicant how many people are in the household and what are their ages.
2. Look for their gross income.
3. Refer to Financial Aid chart to find qualified % amount.

Special Populations - Applicants that product benefit statements for any of the following qualify for 70% financial assistance:

• SNAP
• SSI
• SIC
• Covered California
• CalFresh
• CalWorks
• GoKids
• Free/Reduced Lunch

NOTE: qualified does not mean approved. We are recording eligibility. Executive Directors determine whether there are funds available.

Staff Name: Staff Name: First Last
Applicant Information:
Applicant Name Applicant Name First Last
Customer ID
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Please choose from the following options:
Location
Request Type
Membership Type
Start Date Start Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Program Purchasing Group
Applicant Qualifies for:
Notes
Please do not leave notes regarding income.
Income Chart:

Financial Assistance | Documentation Review & Executive Approval Requests

Financial Assistance | Documentation Review & Executive Approval Requests

Applicant Information:

Income Chart: