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Leisure Bucks Financial Assistance Online Application

Steps

1. Applicant Information(current) This section is complete This section is incomplete
2. Qualifications This section is complete This section is incomplete
3. Spouse/Partner Applicant This section is complete This section is incomplete
4. Youth Applicants This section is complete This section is incomplete
5. Applicant Signature This section is complete This section is incomplete

Applicant Information

Program Information
The Leisure Bucks financial assistance program provides qualified applicants of all ages up to $100 to use towards individual recreation programs provided by the Parks, Recreation and Neighborhoods Department. Funds are available July 1st through June 30th. Any unused funds will be forfeited.
Recipients must be Modesto residents AND meet HUD Guideline income requirements OR be enrolled in an accepted financial assistance program. Verifying documentation is required for you and/or your household members to qualify.
This online application requires verification documents to be uploaded. If documentation is unavailable, please apply in person at the Parks, Recreation and Neighborhoods Department at 1010 Tenth Street, 4th Floor, Modesto, CA 95354.
Title II Compliance
In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit https://www.modestogov.com/865/Americans-with-Disabilities-Act-ADA.
Instructions
Provide your name and contact information in the section below.
If more than one person is on the application, fill out the section below with the primary person or parent/guardian's information.
First Name*
Primary/Parent/Guardian
Last Name*
Primary/Parent/Guardian
Telephone Number*
Primary/Parent/Guardian
Email Address*
Primary/Parent/Guardian
Residence Street Address*
Primary/Parent/Guardian
City*
Primary/Parent/Guardian
State*
Primary/Parent/Guardian
Zip Code*
Primary/Parent/Guardian
Is this a renewal application?*
1. Yes
2. No
Previous Leisure Bucks Number
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Family Size	Annual Income
1	$55,200
2	$63,050
3	$70,950
4	$78,800
5	$85,150
6	$91,450
7	$97,750
8	$104,050

Spouse/Partner Applicant

Are you adding a spouse/partner to this application?*
A spouse/partner can be added to this application provided they meet qualifications.
1. Yes
2. No
First Name*
Spouse/Partner
Last Name*
Spouse/Partner
Date of Birth*
Date of Birth
Spouse/Partner
Which submitted document verifies your spouse/partner as part of your household? (check all that apply)*
The spouse/partner must be named on at least one of your submitted documents to meet qualifications.
1. Submitted Utility Bill (Modesto Resident or Financial Assistance Document)
2. Submitted Financial Assistance Program Document
3. Submitted HUD Income Document (1040 Tax Return or 4506-T Form)
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Applicant Signature

Additional Information
Please provide any relevant additional information needed to process your application.
PENALTY FOR FALSE OR FRADULENT STATEMENT*
U.S. Code, Title 18, Section 1002, provides that a fine of up to $10,000 or imprisonment for a period not to exceed 5 years, or both shall be the penalty for willful misrepresentation and the making of false, fictitious or fraudulent statements, knowing to be false.
1. I certify the submitted information is accurate and true to the best of my knowledge.
Signature*
Primary/Parent/Guardian's Full Name
Today's Date*
Today's Date
End of Application
Our Customer Service Staff will contact you within 2 weeks regarding this application.

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1. Receive an email copy of this form.
Email address

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Leisure Bucks Financial Assistance Online Application

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Qualifications

Spouse/Partner Applicant

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