Application for Financial Assistance Date* MM slash DD slash YYYY Applicant Name:*Applicant's Age:*Applicant Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address of Parent/Guardian of Applicant* Phone number Parents/Guardians of Applicant*Description of request for financial assistance (e.g., what funds will be used for), including name of child/athlete:*The foundation generally offers financial assistance to families whose total annual income is less that $75,000 and have one or more children/dependents. The Foundation may also offer financial assistance to families who do not meet either of the above criteria but who have other circumstances, including financial hardship, that may also require financial assistance.To apply for financial assistance, please check the appropriate box and provide required information below.* I and my spouse (if applicable) had total annual income for the most recently completed year of less than 75,000, do not reasonably expect to exceed such level of income in the current year, and have one or more children/dependents. I and my spouse (if applicable) had total annual income for the most recently completed year of less than 100,000, do not reasonably expect to exceed such level of income in the current year, and have one or more children/dependents. I do not meet either of the criteria for financial assistance set forth above but desire to seek financial assistance based on other circumstances or financial hardship. (In addition to providing the information in the table below, you must also provide a reasonably detailed description of our circumstances or financial hardship in the “Additional Information” section below.) Family Income*Family IncomeSingle IndividualSpouseChildren (under 18 or full-time student)Other dependents allowed for income tax purposesOther dependentsMEMBERS OF FAMILY (# OF PERSONS)*SALARY BEFORE OTHER INCOME*Total Family Size*TOTAL GROSS INCOME*Additional information (must be completed if you are applying for financial assistance but do not meet either of the annual income criteria for assistance):*An IRS Form W-2 or other applicable form must be provided to support the information set forth above. The Foundation may also ask for additional supporting documentation as it determines to be reasonable.You will acknowledge that there is no assurance that you will receive financial assistance, even if you meet either of the annual income criteria for assistance. Any and all financial assistance including a determination to grant financial assistance and the amount thereof (if any), will be determined by the Foundation in its sole discretion based on a variety of factors, including, without limitation, available funds, the number and needs of other applicants, and other relevant factors as may be considered by the Foundation.
