Holyoke Creative Arts Center
P.O. Box 4998 - 400 South Elm Street
South Street Plaza off I-391 - Holyoke, MA 01041
Telephone (413) 532-0465 - Fax (413) 532-2278
www.holyokeCAC.org
HOLYOKE COMMUNITY DEVELOPMENT BLOCK GRANT APPLICATION
If you are a resident of Holyoke, you might qualify for a scholarship for classes at the Holyoke Creative Arts Center. To find out if you qualify, please Print this page, fill in the information and mail, fax or bring it to the Center

A. Persons in your Household (including yourself) _________

B. For the line corresponding to your family size above, please check if your Household Income falls below this level. (If not, leave blank)
Family Size
1 person5 persons
$10,950______  
$18,250______  		 $20,160______  
$29,200______  		     $16,900______  
$28,150______  		 $31,080______  
$45,000______  

2 persons6 persons
$12,500______  
$20,850______  		 $23,040______  
$33,350______  		     $18,150______  
$30,200______  		 $33,420______  
$48,350______  

3 persons7 persons
$14,050______  
$23,450______  		 $25,920______  
$37,500______  		     $19,400______  
$32,300______  		 $35,700______  
$51,700______  

4 persons8 persons
$15,650______  
$26,050______  		 $28,800______  
$41,700______  		     $20,650______  
$34,400______  		 $38,040______  
$55,000______  


CLASS ___________________ DAY______ TIME_________ SESSION_________

Please print:

NAME________________________________ TEL. NO._____________________

ADDRESS___________________________________________________________

ETHNIC BACKGROUND______________________________________________

DATE______________ SIGNATURE______________________________________

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