Financial Needs Assistance Application

Household Information:

Please include all people living in the house for whom you contribute at least 50% of financial care, including yourself.

If you are potentially eligible, we will ask you to bring into the office one of the following documentations::

• Copy of AGI page of Federal Tax Return (1040—line 37; 1040A—line 21; or 1040EZ—line 4)
• Current copy of all W-2s for all working members of the household
• Two most recent pay stubs for all working members of the household for all current jobs
• Letter of extenuating circumstances (if applicable)

Acknowledgement of Financial Needs Assistance Policy:

When receiving financial needs assistance funding, I agree to pay the difference in tuition. I understand that if I fail to pay or prepay, and/or my student fails to attend sessions on a regular basis, financial assistance funding will cease. If my student misses a session and adequate notice (six-hour minimum) is not given to the EPLP tutor, I will be responsible for the entire amount for the session ($48) as the financial needs assistance will not be eligible for that session.

You will be notified of your financial needs assistance status within 14 days of receipt of completed application. If your application is incomplete, you will be required to submit additional information before consideration. An interview may be required to help clarify application and provide additional information to determine Financial Needs Assistance eligibility.

If you have any questions or concerns about this application, please contact Sue Yowell at 970-577-0020 or sueyowell@eplearningplace.org.