CC Resolution 10960
Attach 1
RESOLUTION NO. 10960
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF CAMPBELL APPROVING A
FINANCIAL ASSISTANCE PROGRAM POLICY
WHEREAS, an informal policy relating to use of private funds to support financial
aide for underserved youth has been in existence since 1994; and
WHEREAS, there is a desire to strengthen and formalize this policy; and
WHEREAS, there has been submitted to the City Council a more formalized policy
statements; and
WHEREAS, the Policy has been reviewed by the City Council;
NOW, THEREFORE BE IT RESOLVED, by the City Council of the City of
Campbell that a new Financial Assistance Program Policy is adopted as submitted.
vote:
PASSED AND ADOPTED the 21st day of October, 2008 by the following roll call
AYES: Council members
Furtado, Kennedy, Low, Hernandez, Burr
NOES: Council members
None
ABSENT: Council members
None
APPROVED:
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ATTEST:
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Uonald R. Burr, Mayor
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Anne Bybee, City Clerk
Attachment 2
SECTION 18
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Subject: Financial Assistance Program Policy
Date: October 21,2008
I. PURPOSE
The City of Campbell recognizes the value of participating in recreational
programs for youth and teens. Acknowledging that the financial
circumstances of some residents may impose a barrier to youth and teens
in accessing fee based Recreation & Community Services programs and
in an effort to make its recreational programs and activities available to the
widest range of residents, the City of Campbell established the Financial
Assistance Program (FAP) to assist economically disadvantaged youth
and teens to enable them to participate in the Recreation & Community
Services classes and programs. This program is made possible through
the generous donations of local service clubs, businesses and private
individuals. To that extent, funds are limited and will be distributed on an
'as available' basis. Recipients of financial assistance are encouraged to
participate as program volunteers as appropriate to further contribute to
the program.
II. ELIGIBILITY
The City of Campbell offers financial assistance to resident youth (17
years and under) for participation in the Recreation & Community Services
Department's program offerings. Proof of Campbell residency and low
income verification is required. Applicants must meet the maximum
gross income criteria established by the U.S Department of Housing &
Urban Development based on family size.
III. APPLICATION REQUIREMENTS
A FAP application must be completed by the youths' parent or legal
guardian. Incomplete applications will not be processed. A 'Household' is
defined as a group of related or non-related individuals living as one
economic unit and sharing living expenses. Living expenses include rent,
clothes, food, doctor bills, and utility bills. The following items are required
to be submitted along with the complete application:
One of the following acceptable proofs of income/financial are needed:
a. Proof from the school district that your child is eligible for free or reduced
price meals.
b. Proof that your household is receiving Food Stamps, Cal WORKS
assistance (California Work Opportunity and Responsibility to Kids), TANF
I
SECTION 18
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Subject: Financial Assistance Program Policy Date: October 21,2008
(Temporary Aide to Needy Families), or Kin-GAP (Kinship Guardian
Assistance Payments).
If you do not have either of the above two forms of documentation, a copy of your
last Federal Income Tax Return (form 1040/1040EZ/1040NR) showing that you
fall under the income eligibility guidelines listed on the application. Your
household size must equal the number claimed on your income tax form.
In the rare circumstance where a Federal Income Tax Return has not been filed,
you will need to submit pay stubs from the previous 30 days to the date of
application.
You will also need to provide a copy of your valid Driver's License or State
Identification Card. If you are a foster family, you will need a letter from your
certifying Foster Agency.
Monthly income means the amount of income each household member receives
on a monthly basis (before taxes or other deductions are taken out) and where it
came from, such as earnings, welfare, pensions, social security, tips, strike
benefits, unemployment compensation, worker's compensation, disability
benefits, child support, alimony, cash withdrawn from savings, interest/dividends,
rental income and any other source of income. If the amount varies from month-
to-month, please indicate the normal average monthly amount.
IV. REQUEST PROCESSING
Requests are awarded on a first-come, first-served basis and are funded only as
long as there are available resources. Assistance is issued for registration fees
only, not for supplies or other costs. Submittal of an application is not a
confirmation into the class or confirmation of fee assistance. The parent/legal
guardian must pay for the co-payment (the remaining amount of the class). A
recipient is not assured a place in the program/class and is not considered
registered until the co-payment has been received. Co-payments must be clear
and be in cash, valid check, or VISA/MasterCard/Discover. Any past due
accounts must be brought current before a FAP application is considered.
Recipients are responsible for their own transportation to and from activity sites.
Applicants who falsify information or do not attend class regularly may be
ineligible for future fee assistance. If extenuating circumstances prevent regular
attendance, please call the office at (408) 866-2104.
Select the class/program that is appropriate for your child's age and ability as a
transfer request to a different activity will not be granted after the FAP application
SECTION 18
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Subject: Financial Assistance Program Policy Date: October 21,2008
has been processed. Fee assistance will not be applied retroactively. Unused
funds are not carried as credits on your account and are not transferrable.
The maximum funding allowance per child is $100 per calendar year with a
maximum annual benefit of $200 per household dependant on availability of
funds. The calendar year is January 1 through December 31. To the extent
permitted by State Law; family size, household income and Social Security
information will remain confidential and will not be shared for any purpose.
V. FOSTER OR INSTITUTIONALIZED CHILDREN
Use one application per foster or institutionalized child who is the legal
responsibility of the welfare agency or court. Write the name of the foster or
institutionalized child and the specific school the child attends. If the foster child
or institutionalized child receives "personal use income", list the amount of the
income. "Personal Use Income" is (a) money given by the welfare office
identified by category for the child's personal use, such as clothing, school fees
and allowances, and (b) all other money the child receives, such as money from
his/her family and money from the child's full-time or part-time jobs. The foster
parent or agency official must sign the application.
YEAR:
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CITY OF CAMPBELL
FINANCIAL ASSISTANCE APPLICATION
(One Form per Child - Please Print or Type)
Name
Parent/Guardian
Home Phone
Cell Phone
Home Address
City
Employer
Zip Code
Work Phone
Parent/Guardian Marital Status: ( ) single ( ) married ( ) divorced ( ) widowed
Spouse's Name
Spouse's Employer
Work Phone
Number of Adults in Home
Number of Children in Home
Children/Dependents:
1.
2.
3.
4.
Birth date
Birth date
Birth date
Birth date
School
School
School
School
Relation
Relation
Relation
Relation
Please list your reason for assistance. Explain any special circumstances you may wish us to
consider:
PROGRAM FOR WHICH YOU ARE SEEKING ASSISTANCE:
Name Class # Program Title Fee$
Name
Class #
Program Title
Fee$
Name
Class #
Program Title
Fee$
PLEASE COMPLETE INFORMATION ON OTHER SIDE
Have you received Financial Assistance from the City of Campbell, Recreation & Community
Services Department before? Yes No
If yes, what program(s) did your child attend?
What year(s) did you receive assistance?
I certify that the above information is true and correct and I understand that the information
provided here will be relied upon for purpose of determining our eligibility to receive financial
assistance from the City of Campbell Recreation & Community Services Department and that
any misstatement, fraudulently or negligently made in this or in any other statement by me may
result in the denial of my eligibility to receive financial assistance. I authorize the City of
Campbell to verify the above information. I agree to provide additional documentation to verify
my need if requested.
Signature
Date
D I would like the City to keep this information private to the extent permitted by law. Please
notify me before releasing this information to anyone outside of the City.
Please provide one of the following:
1. Proof from the school district that your child is eligible for free or reduced price meals.
2. Proof that your family is receiving Food Stamps, CalWORKS assistance (California
Work Opportunity & Responsibility to Kids), TANF (Temporary Aide to needy
families), or Kin-GAP (Kinship Guardian Assistance Payments).
If you do not have either of the above, a copy of your last Federal Income Tax Return (form
1040/1 040EZ/1 040NR) showing that you fall under the income eligibility guidelines listed
below. Your household size must equal the number claimed on your income tax form.
In addition to the above, you must provide one of the following for residency verification:
1. Copy of Driver's License or State Identification.
2. Last three months' utility bills.
Office Staff Use Only
Date scholarship approved
Percentage of scholarship
Amount of scholarship
F: Scholarship Program/New application 2008
Date
FOR OFFICE USE ONL Y
HUD Income Guidelines - Updated 2008
ANNUAL INCOME
100% Scholarship 50% Scholarship
Extremely Low- Very Low- Income
Household Income (50% of median)
Size (30% of median)
1 $23,750 $39,600
2 $27,150 $45,250
3 $30,550 $50,900
4 $33,950 $56,550
5 $36,650 $61,050
6 $39,350 $65,600
7 $42,050 $70,100
8 $44,800 $74,650
HUD Income Guidelines - Updated 2008
MONTHL Y INCOME
100% Scholarship 50% Scholarship
Extremely Low- Very Low- Income
Household Income (50% of median)
Size (30% of median)
1 $1,979 $3,300
2 $2,263 $3,771
3 $2,545 $4,242
4 $2,829 $4,713 I
5 $3,054 $5,088
6 $3,280 $5,467
7 $3,504 $5,842
8 $3,734 $6,221
J: Scholarship Program/New Financial Guidelines 2008