City of Las Vegas Department of Parks, Recreation and Cultural Affairs

Financial Assistance Request

Calendar Year 2024


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Are you applying on behalf of a foster child/children?*
Family Service Letter of Custody*
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If you are applying on behalf of a foster child/children, please list only the name(s) of the foster child or children below and provide Photo ID and Family Services letter of custody for foster child/children. If you wish to apply for Financial Assistance for any other household members who are not foster children (i.e. biological children, grandchildren, etc.), you must apply separately and provide your total household income along with copies of all applicable documents.

Customer Information

Primary Guardian*
Date of Birth*
Upload Photo ID Primary Guardian*
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Secondary Guardian?
Secondary Guardian*
Date of Birth*
Upload Photo ID Secondary Guardian*
No File Chosen
File uploads may not work on some mobile devices.
Address*

Additional Household Members

Please list only the name(s) of the foster child or children below.

Household Member 1*
Relationship to Guardians*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member
Add Member?
Household Member 2*
Relationship to Guardians*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member
Add Member?
Household Member 3*
Relationship to Guardians*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member
Add Member?
Household Member 4*
Relationship to Guardians*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member
Add Member?
Household Member 5*
Relationship to Guardian*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member
Add Member?
Household Member 6*
Relationship to Guardian*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member
Add Member?
Household Member 7*
Relationship to Guardian*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member
Add Member?
Household Member 8*
Relationship to Guardian*
Date of Birth*
Enter 0 if no income
Requesting scholarship for this member

Document Upload

Does any member of your household:
Receive or expect to receive any of the following:
Upload monthly income statement for primary guardian*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement for primary guardian
No File Chosen
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Upload monthly income statement for secondary guardian*
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File uploads may not work on some mobile devices.
Upload second monthly income statement (If needed)
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File uploads may not work on some mobile devices.
Upload monthly income statement 1*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement 2*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement 3*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement 4*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement 5*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement 6*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement 7*
No File Chosen
File uploads may not work on some mobile devices.
Upload monthly income statement 8*
No File Chosen
File uploads may not work on some mobile devices.
Public Housing or Section 8 rental assistance*
No File Chosen
File uploads may not work on some mobile devices.
Public assistance- welfare*
No File Chosen
File uploads may not work on some mobile devices.
Unemployment benefits*
No File Chosen
File uploads may not work on some mobile devices.
Child support*
No File Chosen
File uploads may not work on some mobile devices.
Alimony*
No File Chosen
File uploads may not work on some mobile devices.
Social Security or other retirement benefits*
No File Chosen
File uploads may not work on some mobile devices.

I/we certify that the information given on the household information and income is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable by law. I/We also understand that false statements or information are grounds for termination of assistance. I consent to verification of this information by the service provider, the city of Las Vegas, or other governmental officials are required. In the event your income changes due to marriage, divorce, births, deaths, promotions, termination, etc., you must provide documentation to that effect and updated income statements in (10) business days for financial aid recertification.

Use your mouse or finger to draw your signature above
Date Signed

Staff Approval

Recomendation*
Please choose the reason for denial.
This text will be emailed to the customer as the reason for denial

If no percentage is showing, family does not qualify for Financial Aid

I have reviewed all the customer's information and agree all information is correct. I have also confirmed that the form matches the customer's account information in CivicRec.

Coordinator*

Description Area

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Additional Notes if needed

Process Application

$
Approval % Rate*
Date Entered into CivicRec
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