Park District of Oak Park

Scholarship Distribution Chart If approved, available monies will be allocated per individuals as displayed here. Income Level % Scholarship/ % Fees Required Tier 1 75%/25% Tier 2 55%/45% Tier 3 35%/65% Childcare Discount Membership Allocation Chart If approved, discount membership will be applied to eligible dependent. Income Level Discount/ % Fees Required $0-$39,000 55%/45% $39,001-$65,000 40%/60% $65,001-$100,00 25%/75% Circle Household Size and Income: (Scholarship Applicant only) Household Size (Please Circle One) Tier 1 (Fees Covered) Scholarship / Participant 75% / 25% Annual Income Tier 2 (Fees Covered) Scholarship / Participant 55% / 45% Annual Income Tier 3 (Fees Covered) Scholarship / Participant 35% / 65% Annual Income 1 17,667 25,142 32,616 2 23,803 33,874 43,944 3 29,939 42,606 55,272 4 36,075 51,338 66,600 5 42,211 60,070 77,928 6 48,347 68,802 89,256 7 54,483 77,534 100,584 8 60,619 86,236 111,912 Each additional family member add +6,136 +8,732 +11,328 Financial Assistance Program 2023 January 2023-December 2023 Note: Applicant's income will be verified with tax return, paycheck stub, or other appropriate document. Note to Parent/Guardian: Please circle the size of your household and your total household income below, and sign to verify your income. Household income must be equal to or less than the amounts listed for each pay period for your child to be eligible for the scholarship. You will need to present documentation verifying your income. Income is defined as any monies earned before any deductions such as income taxes, social security taxes, insurance premiums, charitable contributions, and bonds. It includes the following: (1) monetary compensation for services, including legal wages, salary, commissions or fees; (2) net income from non-farm self employment; (3) social security; (4) dividends or interest on savings, bonds or income from estates or trusts; (5) net rental income; (6) public assistance or welfare payments; (7) unemployment compensation; (8) government civilian employment or military annuities; (9) private pension or annuities; (10) alimony or child support payments; (11) regular contributions from persons not living in the household; (12) net royalties; (13) other cash income. Other cash income would include cash amounts received or withdrawn from any source including savings, investments, trust accounts, and other resources that would be available. OR If your family is faced with extraordinary bills, obligations or other responsibilities, please indicate below with an explanation why payment is not possible at this time. *Please submit application along with proof of income, residency, and dependents to the Park District of Oak Park. Acceptable proof can be found on www.pdop.org/findaid I hereby certify that all information on the application is true and accurate. Scholarships are legally recoverable if paid and awarded based on false information supplied by the applicant. The submission of false information will nullify any request for waiver of program fees. Signature of Applicant's Parent/Legal Guardian Date

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