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Salem Park, Recreation and Community Services Financial Assistance Application Child’s Name: Parent’s Name: Home Address: Parent’s Email: The following information is required to determine your eligibility for financial assistance. Total Household Gross Income 1. Select the column that corresponds to your household size. 2. Circle the income range that corresponds to your total household gross income Total Number of People In Household Total Household Gross Income 1 Person 2 People 3 People 4 People 5 People 6 People 7 People 8 People Under $28,200 Under $32,200 Under $36,250 Under $40,250 Under $43,500 Under $46,700 Under $49,950 Under $53,150 $28,201- $47,000 $32,201- $53,700 $36,251- $60,400 $40,251- $67,100 $43,501- $72,500 $46,701- $77,850 $49,951- $83,250 $53,151- $88,600 $47,001- $70,750 $53,701- $80,850 $60,401- $90,950 $67,101- $101,050 $72,501- $109,150 $77,851- $117,250 $83,251- $125,350 $88,601- $133,400 Over $70,750 Over $80,850 Over $90,950 Over $101,050 Over $109,150 Over $117,250 Over $125,350 Over $133,400 In signing this form, I certify that all of the information provided above is true and correct to the best of my knowledge and belief and that no information has been excluded, which might reasonably affect a judgment regarding eligibility. I authorize the funding agency and/or the City of Salem to obtain verification from any source I provide. Name (printed) Signature Date: Office Use Only: Program Name: Cost of the Program: Amount of financial assistance awarded: Staff Signature: ---PAGE BREAK---