Financial Assistance Form for In-Theater Programs
Date
*
-
Month
-
Day
Year
Date
Section 1:
Name of Dependent Child that would benefit from this assistance:
*
The program(s) for which you are requesting assistance:
*
Summer Camps
Vacation Camps
Play Me a Story
Classes
Other
Applicant’s Information:
Name:
*
First Name
Last Name
Relationship to participant:
*
Primary Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant’s Employer:
*
Supervisor:
*
Employer’s Phone:
*
Please enter a valid phone number.
Are there any additional adults contributing to the financial support of the child?
*
Yes
No
Additional contributing adult information will be:
Included below
Sent separately from this form (Please email education@portlandstage.org)
Name of additional contributing adult:
First Name
Last Name
Primary Phone Number:
Please enter a valid phone number.
Email
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer:
Supervisor:
Employer’s Phone:
Please enter a valid phone number.
Additional Dependents/Children (if applicable):
1. Name, DOB, Age, Relation
2. Name, DOB, Age, Relation
3. Name, DOB, Age, Relation
4. Name, DOB, Age, Relation
5. Name, DOB, Age, Relation
Section 2:
If you are on Public assistance please check the appropriate item:
*
Not applicable
AFDC
EAEDC
Veteran’s Benefits
Food Stamps
Other
Please submit a copy of your card or other verification:
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Section 3:
Monthly Income (designate type of income and amount received each month): **Please attach documentation from any source of income you are receiving. All contributing guardians or adult household members who are working are asked to submit a copy of check stubs from the last three weeks.
Wages (before taxes, etc. are taken out):
Attach file here:
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SSI Amount:
Attach file here:
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AFDC Amount:
Attach file here:
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Unemployment Amount:
Attach file here:
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Disability Amount:
Attach file here:
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Child Support Income:
Attach file here:
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Total Monthly Income:
*
Any additional documents:
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Any additional documents:
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Section 4:
Total current value of any accounts (investment, checking, and retirement):
*
Section 5:
What do you feel you could contribute, if any, to the cost of the program?
*
Section 6:
Have you received financial assistance in the past from Portland Stage Company?
Yes
No
If yes, for what program, when and how much?
Section 7:
The statements and responses I have given are true and correct.
Signature
Please return this form and necessary verification to:
Michael Thomas, Education DirectorJulianne Shea, Education Administrator Portland Stage Company P.O. Box 1458Portland, ME 04104
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