Required fields are marked with asterisks (*)

Recreation Fee Assistance

Please complete this form for consideration for the City of Belleville Recreation Fee Assistance. Please note, you must be a City of Belleville resident/taxpayer.

Participant Name

Date of Birth

Address

Apartment/Unit

City or Town

Province

Postal Code

Phone Number (Main)

Phone Number (Other)

E-mail Address

Gender

Male

Female

Prefer not to say

Please list the family members who reside at the Main Contact Household.

Name

Date of Birth

Gender

Male

Female

Prefer not to say

Add Remove

Combined Before Tax Household Income (all members 18 years of age and over)

Pleaes Note: This form must be signed by all adult members of the household (non-dependants 18 and over must fill our their own subsidy application).

I/We certify that the information in this application is true and completed to the best of my/our knowledge. I/We understand that any falsified information on this application can result in the termination of any/all financial assistance through this program.

Signature of Main Contact

Clear

Today's Date

Signature of additional family members, 18 years and older

Clear

Today's Date

Signature of additional family members, 18 years and older

Clear

Today's Date

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