Rider Assistance Application Form

Rider Financial Assistance Application

Through fundraising activities and grants from private foundations, Main Stay is able to offer assistance to qualifying clients on a sliding scale based on income. Main Stay uses the income levels as established by the Illinois Free and Reduced Lunch Program. Current information on these income levels is listed below.

  • Riders who meet the criteria for free lunch based on income level will pay $10 per lesson.
  • Riders who meet the criteria for reduced lunch based on income level will pay $15 per lesson.

Riders must complete the Financial Assistance Application and provide their most recent income tax return for review. Please include all income sources. Incomplete applications will not be considered.

Riders will be eligible to and must apply for funding each year, however, funding may only be awarded to eligible riders for up to three years. Please note that financial assistance is not guaranteed even if you meet the criteria. Funds are limited and are awarded based on the sole discretion of Main Stay.

Main Stay requires that riders who receive financial assistance stay current with their lesson fee payments or the rider will become ineligible for assistance.

Your documented income must fall within the Illinois Free and Reduced Lunch Program income levels (listed below) to qualify:

  1.3 (Free Lunch)
$10/Lesson		 1.85 (Reduced Lunch)
$15/Lesson
Family of 1

$19,578 or less     

 $27,861 or less
Family of 2 $26,572 $37,814
Family of 3 $33,566 $47,767
Family of 4 $40,560  $57,720
Family of 5 $47,554 $67,673
Family of 6 $54,548 $77,626 
Family of 7 $61,542 $87,579
Family of 8 $68,536 $97,532
Client Name
Client Name
First
Last
Client resides with
Client's marital status
Client submits his/her own Federal and State taxes?
If no, who claims the client for tax purposes

The client or individual who claims the client for tax purposes must submit a current income tax return along with the application.

Please list the amount received from each of the following sources for all family members that apply:

$
$
$
$
$
$
$
Which session(s) are you requesting financial assistance?

The Mental Health Resource League is a large contributor to our Rider Assistance Fund. Volunteers are needed for their craft fairs and the funds given to Main Stay are directly related to the number of volunteers who assist at their events.

Please indicate which fundraising activity you will participate in

Maximum file size: 52.43MB

Information provided in this application will be kept confidential.

I certify that the information provided in this application is correct to the best of my knowledge.