YOUTH ASSISTANCE SCHOLARSHIP PROGRAM
INTAKE FORM
Applicant Name: (Last) (First)
Phone #: Email: @
This is a federally funded program. For reporting purposes only, please use the following demographic codes when reporting the race/group of household members
on the application. Please check the head of household box in the box below.
Household Information
A FEMALE heads the household
where this client resides.
A MALE heads the household
Where this client resides.
Applicant Signature Date
1. The two ethnic categories to choose from are defined below. You should check one of the two categories.
a. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term “Spanish
origin” can be used in addition to “Hispanic” or “Latino.”
b. Non Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
2. The five racial categories to choose from are defined below. You may mark one or more.
a. American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who
maintains tribal affiliation or community attachment.
b. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
c. Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black”
or “African American.”
d. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
e. White. A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
FOR STAFF USE ONLY
Date of Intake _______/______/________
Staff Signature _____________________________
Family Income Information
LMA Projects 570.201 (a) (1) Type of documentation provided to verify residency ______________________________
LMC Projects 570 208 (a) (2) (i) (A) Groups Presumed to principally be of Low-and Moderate income
________Client provided documentation to verify ONE OF THE FOLLOWING:
Elderly person, abused child, severely disabled, homeless, battered spouse, illiterate adult, person with AIDS, migrant farm worker. Attached type of documentation
provided.
NO EARNED INCOME STATEMENT
Please complete this form if you do not have any earned income, (example: you only receive public assistance or child support).
I, ________________________________ understand and acknowledge that, as regards to the income reported in this application, I have not received any earned
income for the period reported and acknowledge and understand that qualification for assistance funded under this program is based upon having a qualifying family
income for the number of persons in the household, and that the income levels I have certified to in this statement are current as of the date signed. I am aware that
there are penalties for willfully and knowingly giving false information on an application for Federal or State funds. Penalties for falsifying information may include
immediate repayment of all Federal or State funds received and/or prosecution under the law. I understand that the information on this form is subject to verification.
Signature of Applicant Relationship to child Date
American Indian or Alaska Native
Black or African-American
Native Hawaiian or Other Pacific Islander
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