Application for Subsidized Monthly Fee (A+ Program)

Application for Subsidized Monthly Fee (A+ Program)
Note: Application for each household if there is joint custody.

If you are currently receiving financial assistance from Department of Human Services (FTW) Program, you do NOT have to complete Section 2 below, however, you must provide the A+ Program with Form DHS 728 from the FTW Program office.
School Name*
1. Children's Names in A+ Program

First and Last Names*

2. MONTHLY INCOME OF PARENT/LEGAL GUARDIAN LIVING IN HOUSEHOLD

To figure/convert to monthly income: Weekly income x 4.33, Income every 2 weeks x 2.15, Twice a month income x 2

	List the names of all children and parent/legal guardian living in your household. Include yourself and the children listed in step 1	Gross MONTHLY Earnings (Before deductions)	MONTHLY Welfare, Alimony, Child Support & Social Security	MONTHLY Pension or Retirement Payments	Any OTHER MONTHLY Income
1
2
3
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5
6

	Gross MONTHLY Earnings (Before deductions)	MONTHLY Welfare, Alimony, Child Support & Social Security	MONTHLY Pension or Retirement Payments	Any OTHER MONTHLY Income
Total

3. Agreements and Signatures

The information on this form and the attached documentation may be used to assist the determination of eligibility for the After-School Plus (A+) Program’s subsidized monthly fee. A+ Program staff may verify all the information on this form and the attached documentation. I give up my rights to confidentiality for this purpose only. I certify that I am the parent/legal guardian of the child(ren) for whom application is being made. I also certify that all of the above information is true and correct and all income is reported. I understand that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. If any information has been falsified, I understand that this may result in a loss or reduction of benefits, legal claims, and dismissal of my child(ren) from the After-School Plus (A+) Program.
Do you have a form of income?*

YesNo, I will provide a brief explaination below.
Zero Income. You must explain how your living expenses are being met.*
Attach a copy of one of the documentation for every type of income you receive to show that you qualify for a subsidized monthly fee. See Sources of Acceptable Income Documentation listed below.*

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Type of Income	Suggested Sources of Acceptable Written Evidence
Earnings/Wages/Salary	1. For each type of income received, send one of the following: 1. Current paycheck stub (for one month) 2. Letter from employer on official letterhead stating gross wages paid and how often they are paid; or 2. Self-employed, business or farming documents, such as  ledger books, last quarterly tax estimates, last year’s tax return; or 3. Last year’s tax return (gross income) with copy of W-2.
Cash Income	A letter from employer stating wages paid and frequency
Social Security (all types)	1. Social Security Benefit Award letter; or 2. Statement of benefits received.
Pension/Retirement	1. Statement of benefits received; or 2. Pension award notice.
Unemployment Compensation/Disability or Workder's Compensation	1. Benefit Award letter; or 2. 2. Check stub.
Financial Assistance Payments	Benefit statement from DHS (Do not include SNAP).
First to Work	DHS Form 728 from First to Work unit
Child Support/Alimony	1. Copies of checks or proof of payment received; or 2. Court order decree or agreement.
All other income	Documents showing the amount, how often, and date received.
No Income	Provide a brief note explaining how you provide food, clothing, and housing for your household and when you expect income.

1. Children's Names in A+ Program