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City of Lafayette Recreation Department Reduced Rate Program The City of Lafayette provides a program for eligible participants, which will reduce fees by 50% for activities, sponsored by the Recreation Department. This reduced rate program is available to all Lafayette youth whose families meet one of the following guidelines: *Temporary Assistance for Needy Families (TANF) *Food Stamps *Supplemental Social Security Income or S.S.D. *W.I.C. Recipients *Section 8 or Public Housing *Medicaid Recipients *Child Health Plan Plus (CHP+) *Free Lunch Program ***Please Note: Proof will need to be provided at time of application 1. If you meet one of the above standards, you need to completely fill out the attached reduced rate application form. Attach a copy of documentation for the category you qualify for and either mail it in or bring it to the Recreation Center for processing. Applications will not be processed without required documentation. Please note: Medicaid cards will no longer be accepted as proof of Medicaid. If you are a Medicaid recipient, please include documentation from Medicaid stating the eligibility dates for this program. 2. Once the application has been approved, the youth listed on the application will be entitled to one-half (50%) reduction in the resident fee for a selected class or program, up to the amounts listed below. Fees must be paid at the time of registration. Please Note: If you register and pay for a class before your reduced rate is approved, refunds or household credits will not be given. This eligibility is good for one calendar year, January through December. Applicants must apply each year for this program. There is no need to re-apply for reduced rates each time a brochure is published. 3. The family is responsible for any outside materials or equipment not supplied by the program. 4. Classes that are offered on a contractual basis through the City of Lafayette are not eligible for the reduced rate. If you have questions regarding this please contact the Recreation Center at [PHONE REDACTED]. 5. No single child can receive more than $100 in fee reductions per calendar year. Remaining funds are not transferable to any other child. 6. Families that are approved for reduced rates for programs will be notified through the mail. This letter will explain the procedure for using this program. 7. The reduced rate money allotted to each child for the year or for the remaining portion of the year will be prorated based on the date the application is received by the Recreation and Facility Management Department. Please refer to the prorated schedule listed below: If application received before April 30, 2013 Each child receives $100 If application received after April 30, but before June 30, 2013 Each child receives $75 If application received after June 30, but before November 1, 2013 Each child receives $50 FACILITY USE: The City of Lafayette offers a reduced rate plan for those Lafayette residents who apply for assistance and meet Social Services criteria (same as listed above for program fee assistance). Eligible citizens (adults and youth) will be able to buy daily passes at 50% discount. The applications are available at the Recreation Center. These applications may be turned in throughout the year. The reduced rate is good through the calendar year. Applicants must apply each year for this program. ---PAGE BREAK--- ---PAGE BREAK--- CITY OF LAFAYETTE RECREATION DEPARTMENT HEAD OF HOME CELL I believe that I qualify for this program based upon the following guidelines: Please attach a copy of documentation for category checked. Application will not be processed without required documentation. Temporary Assistance for Needy Families (TANF) Medicaid – provide documentation stating eligibility dates. Supplemental Social Security Income (S.S.I) or Social Security Disability Women, Infants and Children Nutrition Program Section 8 or public housing Food Stamps Free Lunch Program Child Health Plan Plus (CHP+) I hereby authorize the City of Lafayette to confirm my status in any of the above mentioned programs. I also release the Department of Social Services, Clinica Campesina, and Boulder County Housing Authority to provide my current status in any of the above mentioned programs to the City of Lafayette. Signature Date I am applying for the following Reduced Rate Program: ____Facility Use Only (2013) ____Programs Only (2013) ____Both (2013) LIST MEMBERS OF HOUSEHOLD BIRTH DATE GRADE OFFICE USE Office Use: Copy of Documentation of Assistance Copy of Identification Signed Lawful Presence Affidavit Date Received Staff ---PAGE BREAK--- All Family Members, ages 18 and above, must provide one of the following forms of identification, and sign the Lawful Presence Affidavit. • Valid Colorado Driver’s License • Colorado Identification Card • U.S. Military Card • Native American Tribal document LAWFUL PRESENCE AFFIDAVIT I, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): □ I am a United States citizen; or □ I am a Permanent Resident of the United States; or □ I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date LAWFUL PRESENCE AFFIDAVIT I, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): □ I am a United States citizen; or □ I am a Permanent Resident of the United States; or □ I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date