Application for Financial Assistance - Main Street Connect

Please note that financial assistance is only available for the PLUS membership level.

Main Street strives to make its programs available to all regardless of ability to pay. Financial assistance is limited to membership fees and is provided based on level of need. If you would like to request a printable copy of this application, please email us here.

This application is to be completed fully with required supporting documents attached. A personal interview may be requested before consideration of your application. The information you provide in this application will be held in strict confidence and will need to be updated annually. Incomplete applications cannot be processed.

Eligibility and awards will be determined within one week of application submission.

You may SAVE your form and complete it at a later date. This option is available at the bottom of the form.

Main Street Connect Application for Financial Assistance

"*" indicates required fields

Approximately what level of financial assistance do you think you need?*

75% of monthly membership fees

50% of monthly membership fees

25% of monthly membership fees

Name of Applicant*

First Last

Name of responsible person

Relationship to applicant

Responsible party email address

Responsible party phone number

Applicant's Primary Phone*

Applicant's Email*

Enter Email Confirm Email

Applicant's Address*

Street Address Address Line 2 City State ZIP Code

Applicant's Birthday*

What is your marital status as of today?*

I am single

I am married/remarried

I am separated

I am divorced or widowed

Are you a U.S. citizen?*

Yes

No, but I am an eligible noncitizen

No, I am not a citizen or eligible noncitizen

Please describe your current living situation*

I live at home with family

I live on my own

I live on my own with roommates

Other

Are there other dependents in the household?*

Share names, gender, birthdate, relationship to applicant, school, employment information for each person.

What is the highest level of schooling you have completed?*

Middle school/ Jr. high

High school

College or beyond

Other

Please list other organizations, schools, programs for which you have requested or received financial assistance in the past year*

Please describe your family situation and any exceptional circumstances (financial and otherwise) that contribute to the need for financial assistance. Be explicit.*

What is your occupation?*

Years employed?*

Employer Address*

Assets for applicant, and both parents/responsible party*

Automobiles—own, lease year, make, model, payment; Bank accounts—list all bank/money market/cd’s/brokerage accounts (financial institution, type of account, account numbers; Real Estate Holdings—home, market value, how many years; second home, market value, how many years: Family Retirement plans—current year contributions, total value (for all family members); Other Assets—list and value

Monthly Income Sources (gross for applicant, and both parents/responsible party separately)*

Salary; Child Support; Alimony/child support; Trust, Estates, Partnerships; Unearned Income (interest, dividends, pensions, retirement); Unemployment compensation; Social Security; Welfare/food stamps; Disability, workman’s comp, insurance claims; Gifts, money or property inherited or willed; Scholarships/grants - DDA funding; Other, please specify

Total Monthly Income*

Monthly Expenses (for applicant, both parents/responsible party separately)*

Rent or Mortgage; Real Estate taxes; Maintenance/association fees/landscaping; Utilities (Electric, gas, water, garbage); Cable/internet; Telephone (land and cell); Other Utilities; Food/groceries; Clothing; Laundry/dry cleaning; Household supplies; Medical/dental insurance and unreimbursed expenses; Recreation and Entertainment; Insurance premiums (life, auto, home and other); Car payments; Car repairs/gas; Credit card payments; Alimony/child support; Payment for other dependents living with you; Child care; Child support; School tuition; Travel; Subscriptions (paper, Netflix, Amazon Prime); Charitable contributions; Other expenses, please specify

Total Monthly Expenses*

Do you share household expenses with another adult? Specify*

Are you currently involved in any litigation?*

Yes

Required Supporting Document- IRS income tax returns for the past year.*

When submitting these supporting documents, please be sure to mark out all social security numbers, tax ID numbers and/or credit card numbers prior to submitting your paperwork.

Drop files here or

Max. file size: 50 MB.

Required Supporting Document - W-2 Forms for the past year*

When submitting these supporting documents, please be sure to mark out all social security numbers, tax ID numbers and/or credit card numbers prior to submitting your paperwork.

Drop files here or

Max. file size: 50 MB.

Required Supporting Document - Payroll slips or paycheck stubs for the past two months or a letter from employer verifying employment and annual salary. If not employed, documentation of unemployment benefits i.e., copies of forms of income sources (SSI, Disability, etc.)*

When submitting these supporting documents, please be sure to mark out all social security numbers, tax ID numbers and/or credit card numbers prior to submitting your paperwork.

Drop files here or

Max. file size: 50 MB.

Declaration

I agree to notify MS if my financial situation improves, so that my financial assistance may be re-evaluated, thus providing more opportunities for others in the community. I understand that to maintain my financial assistance, my information will need to be updated annually and that MS may, upon request, require updated financial information. I will be afforded 30 days to provide information when requested. Failure to do so may result in the revocation of my financial assistance or termination of membership.

I declare that the information contained in this application is, to the best of my knowledge, accurate and complete. I understand that failure to answer all questions accurately will disqualify me from consideration.

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